UNIVERSITY OF COLORADO DENVER - DOWNTOWN CAMPUS
INTERNATIONAL STUDENT HEALTH INSURANCE WAIVER FORM
If you are not a CU Denver Downtown student, this is not the correct form. Please locate and complete the waiver form for the correct campus. If you have a questions, please call the Student Office at 303-556-6273
International Students with an F-1 or J-1 visa must submit all waiver appeals no
later than 5:00 pm on the published census date each semester.
Date of Birth:
Please fill out all appropriate boxes
Name of your Insurance Company: *
If Other, please specify:
Insurance Policy Number: *
Insurance Policy Group Number: *
If you have questions while filling out this waiver form, please contact Susie Lederer at email@example.com.
- The deadline date for submission of this waiver form for the Spring 2016 semester will be February 8th, 2016.
- ALL waiver forms will be audited and confirmed with the information
you provided on the waiver form. If your form is incomplete, we will contact you
via email and you will be required to provide additional or missing supporting documentation.
If you do not provide proof of conforming insurance or obtain a waiver from UC Denver
from the insurance requirement by the deadline you will be charged for the University
sponsored insurance premium.
- If you waive the University sponsored plan and incur services at the Health Center
at Auraria, you will have to pay for your charges at the time of service and be
reimbursed for any claims paid through your insurance company (unless your insurance
is Anthem of Colorado). Dependents cannot be seen at the Health Center at Auraria.
- A student who willfully fails to maintain a comparable health insurance policy while
a student at UC Denver or who makes a material misrepresentation to UC Denver staff
or faculty concerning such coverage will be subject to disciplinary action under
the Student Code of Conduct up to and including the possibility of dismissal from