The form "Coker College Residential Health Insurance Information/Waiver" is no longer accepting responses.

Try contacting the owner of the form if you think this is a mistake.

All residential students (excluding International students) are required to show proof of health insurance coverage under a personal or family policy, or be charged a Medical Access Fee for the academic year. If you are an Athlete, you are required to fill out this form in addition to the forms required by the athletic department.

This form is to be completed and signed by August 13, 2015, even if you do not have personal insurance coverage. It is your responsibility to notify the Coker College Student Accounts of any changes that occur to your policy. Loss of coverage must be reported to the office of Student Accounts.

*Please make sure you confirm or check with your healthcare insurance provider that your policy INCLUDES "acute episodic illness" such as ear infections, bronchitis, or sinusitis in the state of South Carolina. If your insurance does NOT cover this, it may be a very costly bill for you to be treated in South Carolina.

*Please note that the Medical Access Fee is not insurance. It is a basic agreement with a nearby provider of Health Care to include routine doctor visits. It should not be considered a form of Health Insurance.

The $200.00 Medical Access Fee ($100 each semester) will automatically be charged to your account. If you have medical insurance, the $200.00 can be waived by completing this form by August 13, 2015.

The Medical Insurance Premium for International students is mandatory and cannot be waived.

What is the student's first name?
Your answer
What is the student's last name?
Your answer
I authorize any insurance company, hospital, physician or other person who has attended/examined the claimant to disclose or release any and all information with respect to any injury/illness, policy coverage, medical history, consultation, prescription, treatment, and/or all copies of medical records. I certify that I am currently participating in the following insurance plan and will continue throughout the school year. I understand that by waiving the Medical Access Fee, I will be responsible for any and all of my medical expenses, and the College will not be responsible for any of those expenses. It is the financial responsibility of the student/patient to make financial arrangements for any unpaid medical expenses incurred.
What is the student's Coker ID number?
For new students, the account holder number on the student's Statement of Account is the student's Coker ID number.
Your answer
What is the student's date of birth?
Do you have private or family coverage?
Does your private or family coverage include coverage for "acute episodic illness"?
For an explanation of this question, please review the third paragraph of the waiver information at the top of this form.
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