SUNY Cobleskill
Waiver Form
Student Health Insurance Plan
Fax 518-255-5819
The Wellness Center, 130 Albany Ave.,Cobleskill, NY 12043
Copy of Insurance Card Front and Back is REQUIRED!!!!!!!!!!!!
The Student Health Insurance policy is designed to meet the needs of students at a reasonable price and will supplement the services
available at the Beard Wellness Center. Taking advantage of this offer may complement the health insurance coverage or managed care
you already have. Please consider the following in making your decision about waiving out of this policy:
If your current coverage is through an HMO or PPO out of the Cobleskill area, services locally may be limited or
may be charged to you at a higher rate. You need to contact your health insurance company to investigate your
coverage in the Cobleskill area.
Your current insurance may not cover the types of expenses most frequently incurred by college age individuals such as
outpatient referrals or may cover them only after a deductible or co-payment; this plan helps cover those expenses.
Coverage through parents’ policies may end on a student’s birthday, i.e. ages 19, 23 or 25
Coverage is available for dependents and/or part-time students by contacting: Beard Wellness Center
Fall coverage: mid-August thru early January. Spring coverage: early January thru mid-August.
If, after careful consideration of the above items, you wish to remove the Student Health Insurance premium charge from your semester
bill, students must demonstrate that they are covered by another health insurance policy. Complete this waiver form and return it with a
CLEAR copy of your health insurance card, before semester check-in to SUNY Cobleskill Wellness Center, 130 Albany Avenue, Cobleskill,
NY 12043 or fax it to 518.255.5819.
I hereby waive participation in the Student Health Insurance program. I acknowledge that I am legally responsible for
any and all medical expenses incurred by myself/spouse/son/daughter while enrolled at SUNY Cobleskill. I understand that it
is my responsibility to notify SUNY Cobleskill and to enroll in the Student Health Insurance Policy should my coverage cease
at any point during enrollment at SUNY Cobleskill. A CLEAR copy of my current health insurance card is attached and may
be used in place of the below policy information. I understand that the Insurance Waiver will not be applied until my
Health and Immunization Record is submitted and complete.
Student Last Name____________________________________ First Name_______________________________________ MI______
Student ID#_______________________________
Mailing Address____________________________________________ City, State_______________________________ Zip_________
Name of Insurance_________________________________________ Member ID (Policy) #___________________________________
Name of Policy Holder_______________________________________ Relationship to Insured_________________________________
Signature of Parent/Policy Holder___________________________________________________ Date___________________________
Signature of Student_____________________________________________________________ Date____________________________
Information regarding the
Student Health Insurance
policy can be found at
The Student Health Insurance policy is a bi-annual policy. Failure to waive out of
this policy through the use of this form will result in your being billed for coverage
each semester. If you waive out and encounter a loss of other health insurance
coverage, it is your responsibility to become enrolled in this policy. You may enroll
in the Student Health Insurance Policy at any time during the semester by
demonstrating proof of a change in your health insurance coverage. Waiving out of
the policy can only occur at the beginning of a semester and should be done
before your arrival on campus. You will be billed and responsible for payment if a
completed waiver is not submitted prior to semester check-in. Waivers will not be
accepted after September 15
for fall semester and February 8
for spring
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