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INSURANCE WAIVER FORM
All full-time undergraduate day students are required to purchase the Student Accident
and Health Insurance Plan offered by the University unless the student is covered
under another policy. Each student will be charged for the coverage unless this form is
completed and returned to the Student Accounts Office on campus, or Online through
WebbConnect no later than August 25, 2015 (or January 12, 2016 for Spring Semester
enrollees).
A copy of the benefits can be viewed by selecting the link for STUDENT INSURANCE
at the bottom of your Online Bill.
Name of Insurance Company ______________________________________
Name of Policyholder _____________________________________________
Policy Number ________________________ Expiration Date ____________
Student ID # __________________________
I attest that _____________________________ is covered under the
Name of Student
above-referenced policy and wish to waive the insurance requirements.
_________________________________
Signature
____________________
Date
INSURANCE WAIVER FORM
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Return by fax, US mail or email:
Fax: 704-406-3055
Gardner-Webb University
Attn: Student Accounts Office
PO Box 7324
Boiling Springs, NC 28017
business@gardner-webb.edu