Summer 2026 Student Insurance Waiver Form

Summer 2026 Student Insurance Waiver Form

Deadline is 5/27/2026. The waiver is good for the Summer 2026 Semester only.

This waiver is for on-campus program students enrolled in 9 or more hours who wish to waive Student Insurance coverage.

Student Insurance may be used along with existing family coverage. Student Insurance is suggested as a way to provide the student guaranteed coverage. There is no network! Students are covered at school, at home, and anywhere they may travel, 24 hours a day, 7 days a week for accidents, illnesses, and other medical conditions including mental health, substance abuse, and maternity. As outlined in the Student Insurance brochure, Student Insurance provides coverage for:
• hospital visits/stays
• ambulance transport
• surgery
• office visits
• lab, x-ray, MRI, CT
• physical therapy
• Student Insurance also reduces copays for formulary prescriptions prescribed by Medical Clinic providers that are provided by Prairie Medical Pharmacy.

The cost is only $95.40 for the entire semester.

Complete all information on this form by the posted deadline. Incomplete and/or late forms will not be accepted.

Important: A waiver is not needed if you are not being billed for Summer Student Insurance. If you are not enrolled in at least 9 hours for Spring, not a graduate assistant, or not an international student enrolled in 3 hours, you are likely not being billed.
Please contact the Student Insurance Office at 217.581.5290 with any questions.

Name Name First Last
ENumber (number only)
EIU Email
Phone Phone - ### - ### ####
For the Summer 2026 semester - Are you a Graduate Assistant

For the Summer 2026 semester - Are you a Graduate Assistant Yes No
For the Summer 2026 semester - Are you an international student

For the Summer 2026 semester - Are you an international student Yes No
Are you a member of any Inter-Collegiate athletic program – Student athletes are not eligible for this waiver

Are you a member of any Inter-Collegiate athletic program – Student athletes are not eligible for this waiver Yes No

Yes - You do not need to complete this form, you are not eligible for this waiver. Athletes are required to be covered by Student Insurance. Please call 217.581.5290 if you have additional questions.
Are you a member of the Cheer team – Cheer team members are not eligible for this waiver

Are you a member of the Cheer team – Cheer team members are not eligible for this waiver Yes No

Yes - You do not need to complete this form, you are not eligible for this waiver. Athletes are required to be covered by Student Insurance. Please call 217.581.5290 if you have additional questions.
How many hours will you be enrolled in on count day (May 27, 2026)

How many hours will you be enrolled in on count day (May 27, 2026) Less than 9 (Student Insurance is not billed unless you are enrolled in an on-campus program with 9 or more hours - form not necessary unless you are a Graduate Assistant or an international student enrolled in an on-campus program taking 3 or more hours). This waiver is not required, you will not be billed. 9 or more (Student Insurance is billed only to students enrolled in an on-campus program, students enrolled in an online or off-campus program are not automatically billed).
In the event of involuntary loss of credible coverage, students may apply for reinstatement in the Student Insurance Plan. Reinstatement Form and evidence of loss must be received within 31 days.

As a reminder, the Plan coordinates with the Student’s primary carrier and provides the student worldwide protection, 24-hours a day. Student Insurance can reduce or eliminate out-of-pocket expenses when your primary does not cover 100% of medical costs because of deductibles, co-payments, limitations on benefits, and out-of-network penalties.

This waiver does not exempt the student from the campus Health Service fee.

The waiver is good for the Summer 2026 Semester only. Deadline is 5/27/2026.

Student athletes and Cheer Team members are not eligible for this waiver
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
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