Late Insurance Waiver Request Form

The late waiver request is only for students who have a valid reason for missing the 30 day normal waiver period. For example, you were outside the United States, you were hospitalized, you did not enroll in your thesis or co-op until after the 30 day period, etc.

To continue the late waiver process, please fill out the required fields below:

First Name

Middle Name

Last Name

Date of Birth

Email Address

Student ID

Gender

Male

Female

Student Type

Undergraduate

Graduate

Doctoral

Student Telephone Number

Please explain why you are submitting this waiver late (outside of the first 30 days of the term)

Student's Address

Insurance Company Name

Full Address of Insurance Company (including street, city, state, zip code, and country)

Policy Number

Insurance Company Telephone Number

Subscriber Name

Subscriber ID Number

Subscriber Relation to Student

I certify that the coverage under this health plan is comparable to coverage under the RIT student health insurance program and I understand I am responsible for my medical expenses once this waiver is submitted. I also certify that my insurance coverage will remain in effect without restrictions providing coverage during the current academic year. The submission of this waiver form including all information herewith constitutes truthful and accurate statements.

Student or Parent's Name

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