2016-2017
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.

Student ID#:
Student Type: (check one)
Last Name:
First Name:
Middle Initial:
Gender: (check one)
Date of Birth:
Mailing Address:
Apt. or PO Box or Rural Route:
City:
Country:
State:
Zipcode:
Telephone #:
E-Mail Address:

Please fill out all appropriate boxes

Waiver Terms

Name of your Insurance Company: *
If Other, please specify:
Insurance Policy Number: *
Insurance Policy Group Number: *
Insurance Company Phone Number: *
Insured Identification Number: *
Are you the Primary Policy Holder?(check one)
If you have questions while filling out this waiver form, please contact Susie Lederer at susanne.lederer-graham@ucdenver.edu.
I. General Information     Yes  No
 
 
 




IMPORTANT NOTES:

  • 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 UC Denver.

Please Check

 To the best of my knowledge, my policy/health plan meets the comparable coverage standards of the University of Colorado Denver, Downtown Campus.

  By checking this box, I agree that I have read all the information on the waiver process as stated above and that I understand and acknowledge my understanding of the waiver process.

 
Questions? Please call ECI Toll Free 866.780.3824