All full time Students MUST maintain adequate health insurance coverage, while registered for classes. If you have existing health insurance coverage or another plan for paying your medical expenses, you must complete the Waiver Form. Please note: Existing Coverage will be verified.    
    Your Customer Service Team at Associated Insurance Plans International, Inc. can be reached at 800-452-5772. Our telephones are staffed Monday through Thursday 9:00am - 5:00pm, Friday 9:00am - 12:00pm Central Standard Time. Email us at office@aipstudentinsurance.com.    
    Please be sure to provide as much accurate information as possible. Providing false information is considered deceitful. The information you have provided will be verified and submitted to your College or University.
Note: All fields unless otherwise indicated below are required to be filled in. You can find the information needed below on the ID card issued to you by your insurance provider.
 
     
    Personal Information  
Student ID
First Name
Last Name
Date of Birth  (mm/dd/yyyy) Using an incorrect date format will cause you to receive an error upon submission of this form.
Gender  
Address  
City  
State                
Zip    
Email      
Phone    
    Insurance Company or Government Plan Information
Insurance Company  
If Other, provide name  
Phone number  
Email  (Not required)
Individual or Group Policy
Individual Policy #  Individual Policies Only (Not Required)
Group Policy #  Group Policies Only (Not Required)
Membership ID  
Your Plan's Deductible  
Effective Date  (mm/dd/yyyy) Using an incorrect date format will cause you to receive an error upon submission of this form. (Not Required)  
Termination Date  (mm/dd/yyyy) Using an incorrect date format will cause you to receive an error upon submission of this form.(Not required)  
Primary Insured First Name  
Primary Insured Last Name  
Primary Insured Date Of Birth  (mm/dd/yyyy) Using an incorrect date format will cause you to receive an error upon submission of this form.  
Policy Holder Email Address  
   

 

By checking the box next to the items below, I am stating that I understand this document. I have read it in its entirety. Also, I am legally responsible for all medical expenses incurred while attending the above College/University. The College/University will not be responsible for any medical expenses incurred while enrolled/attending school.

I authorize my schools insurance plan administrator to verify my insurance information.

   
    Print Name here to Agree                             Waiver Form Sign Date    
                                                                         (mm/dd/yyyy)  
     Using an incorrect date format will cause you to receive an error upon submission of this form.
       
     
       
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