Health Insurance Waiver

Required for all students

Massachusetts Law mandates that all full-time and qualifying part-time students certify that they have a health benefit plan with Massachusetts comparable coverage. A new Waiver Form must be submitted each academic year. Foreign insurance policies are not accepted. This form must be returned to the Boston Baptist College Business Office by the following deadline: TBD

Personal Information

Name

First Name

Last Name

Date of Birth

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Health Insurance Information

Name of Insurance Carrier

Policy Number

Address of Insurance Carrier

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Policy Holder

First Name

Last Name

Relationship to Student

If the student is the policy holder, please write "self"

ID Number

Phone

Country

(###)

###

####

Checkbox

I have compared my health insurance coverage to the minimum benefit levels and services as detailed in the MA Student Health Insurance Plan regulations (see mahealthconnector.org for more information). I have comparable coverage which will be in force for the entire academic year and therefore choose to waive this plan. By submitting this signed waiver, I acknowledge full responsibility for any medical expenses incurred during my enrollment at Boston Baptist College.

I Agree

Health Insurance Waiver

Required for all students

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