Health Insurance Waiver Request -
Term:______________________
You will be charged for the health insurance arranged by Drexel ELC after this date. It is not refundable.
You may not attend classes without insurance.
Waiver Request Deadline: FIRST DAY OF ORIENTATION
THIS WAIVER MUST BE SIGNED and presented with your insurance policy no later than:
FIRST DAY OF ORIENTATION
I am requesting a waiver from the mandatory Drexel University, English Language Center Health Insurance Plan. In submitting this Health
Insurance Waiver Request, I understand that it is my responsibility to maintain health insurance for myself.
Program
Intensive English
Last Name
Gender
Policy #
First Name
Date of Birth
Company Name
Claims Phone #
Insurance ID #
Coverage Start Date
Sponsor / Company
Coverage End Date
I certify that I have insurance through the policy referenced above and I will maintain this coverage or comparable coverage during my
studies at Drexel ELC.
I have elected to use a private health insurance provider by submitting this waiver request. If the waiver is granted, I release
Drexel University English Language Center from any liability for any issue of medical coverage including cases of medical
emergency.
Date
Student Signature
It is a Drexel University policy that all students must have health insurance during attendance at the university. To use an alternate Health
Insurance Provider, please attach a photocopy of your policy statement showing the following items in English:
•Your full name (first/given and last/family names).
•Your date of birth
•Your insurance ID number, and the Insurance Policy Number.
•The beginning and ending dates of your policy, which must include the entire time you will study at the ELC for the current term.
•Coverage for medical and hospital services for a minimum total of US $500,000 for accident and US $500,000 for
sickness. Please be
sure that the statement explains the types of services provided. Note: travel, repatriation, disability, and/or life insurance are not acceptable
alternative types of coverage.
•Insurance company name, phone and address in the USA for emergency (English-speaking).
•Your plan provides coverage for emergency, non-emergency, inpatient and outpatient care in the Drexel University area (emergency only care
does not satisfy the requirement)
•Your plan provides coverage for Mental Health & Substance Abuse in the Drexel area
•Plans must be provided by a company licensed to do business in the United States – with a U.S. claims payment office and a U.S. phone number
•Your plan provides coverage for pre-existing conditions immediately upon enrollment
•Your plan is not a reimbursement plan (A reimbursement plan requires you to pay for all services up front and out of pocket)
•Waiver Request Form must be submitted by the Waiver Request Deadline listed above.
IMPORTANT!
ELC Administrative Signature & Date
(circle Male or Female)
