Rescind Waiver Online Application
If a student’s comparable coverage is terminated, the student must inform the Student Health Benefits Office within thirty-one (31) days from the loss of coverage date to be covered by the student benefits plans. ONLY THE STUDENT HEALTH BENEFITS OFFICE CAN PROCESS YOUR RESCIND WAIVER FORM.
Student ID Number *
Your answer
Program Name *
Your answer
Your Status *
Campus Study *
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Phone Number *
Your answer
Email Address *
Your answer
Complete Mailing Address including Postal Code *
Your answer
Are you Domestic or International Post-Secondary Student *
If you are an International Post-Secondary Student; please select which insurance plan you wish to opt-in
Please explain in detail the reason(s) for your request to rescind waiver/opt out application: *
Your answer
If you completed the rescind waiver/opt in application in the past. Please provide the Month and Year when you completed the application in the past.
Your answer
Date of Loss of Alternative Coverage *
MM
/
DD
/
YYYY
Date of Commencement of Restored Coverage *
MM
/
DD
/
YYYY
The plan I am choosing is (choose one of the following): *
There are 4 different plans you can choose from at no additional cost. To review the plan overview, you can visit https://wespeakstudent.com/home/47-george-brown-college/domestic-plan
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms