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BLOOMFIELD COLLEGE – STUDENT HEALTH INSURANCE WAIVER
FALL 2008

ATTENTION ALL FULL-TIME STUDENTS

Your bill will include a medical insurance fee of $53. The State of New Jersey requires that all full-time students (3 course units or more) have medical insurance coverage. You may waive this fee if you have your own coverage.

To Waive the Fee: Complete this form and submit to the Bursar’s Office by the first day of scheduled classes for the semester. A brochure outlining the policy is available at the Bursar’s Office.

Name:
(first and last) 		ID #
Address: Last 4 Digits of SS#
 

I will not be joining the Student Health Insurance Plan for the current academic year because I have coverage comparable to the health benefits of the College Plan through my own or my f amily’s membership in the following group or private policy:
 
Name of Insured:
Relation to Student:
Name of Insurance
Company or Group:
Policy or Group
Number:
Address of Company:
Date of Expiration:
 

I fully understand that I am legally responsible for any medical expenses due to sickness incurred during my enrollment at Bloomfield College.