SHI WAIVER APPLICATION CHECKLIST
Attention Students: It is your responsibility to make sure that you have read and understand the information that is listed on the checklist and waiver application form. The SHI Office will not accept incomplete applications and will not make any exceptions for accepting waiver applications before or after the scheduled dates of the waiver period. Please follow the steps below to ensure that you will not be submitting an incomplete waiver application. Bring this checklist form with you when you submit your application in the Student Health Center. The Staff will give this page back to you and this page will serve as your receipt that we have received your application.
Read and complete the attached waiver application. Verify that your policy meets the following minimum UT System requirements: 1. 2. 3. 4. 5. 6. Medical Coverage is $50,000 or more PER ACCIDENT/ILLNESS Deductible is $500 or less Medical Evacuation Coverage is $10,000 or more Repatriation Coverage is $7,500 or more Company: meets federal solvency guidelines (if you are unsure, you may ask your insurance company) Dates of coverage meet or exceed the requirement for the semester
Attach all of the required documentation that is listed for your section on the application. Submit your waiver application in person to the Student Health Center (SSB 4.700) or by email. The Student Health Insurance Office will process waivers within a maximum of five business days. The Student Health Insurance Office will send all communication through your UTD email address only. Complete waiver application should be submitted ONLY ONCE unless otherwise instructed. All documents must be in English. All documents that list any form of currency must be in U.S. dollars. If the documents are in a foreign language, a certified translation will be required with your application. Copies of the entire benefits guide will no longer be accepted; only the summary page is required. Incomplete waiver applications will not be reviewed. Multiple semester waivers will be given for the current academic year only and only if the coverage dates of your policy include the dates of the semesters for which you are making application. Waiver applications will only be accepted during the scheduled waiver period dates.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------This is to certify that the Student Health Insurance Office has received a complete waiver application from _______________________________ _____________________ for the _______________ semester(s). Name UTD ID
SHC Staff Use Only/Date: ______________________
You will receive a decision on your waiver application no more than 5 business days from the date of this receipt. 1 Revised 04/25/2011
STUDENT HEALTH INSURANCE OFFICE THE UNIVERSTIY OF TEXAS AT DALLAS
800 West Campbell Road, SSB 43 Richardson, Texas 75080-3021• (972) 883-2747 FAX (972) 883-2069• Email: stuhealthinsurance@utdallas.edu
Student Health Insurance Waiver Application Based on a Private Insurance Policy
Student Name UTD Email: ________________________________________________ UTD ID: ___________________________ Date of Birth: Visa Type: __________________
Semester(s) for which the waiver is requested: Spring 2013 (1/14/2013-5/29/2013) Summer 2013 (5/30/2013-8/18/2013)
Part 1:
In support of my request for a waiver from the requirement that I enroll in the Student Health Insurance Plan, I certify that I have current health insurance coverage that meets or exceeds the following requirements that will remain in effect for the entire UTD Student Health Insurance coverage period: Yes Yes Yes Yes No No No No $50,000 or more medical benefits for each illness or injury. A deductible of $500 or less. Minimum of $7,500 for repatriation of remains benefit. Minimum of $10,000 for medical evacuation benefit.
