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Forms » Health Insurance Waiver

Use this form to waive the premium for the UT Arlington Student Health Insurance plan if you have purchased other insurance which meets or exceeds the requirements listed below.
Waiver will be granted only for the dates of the mandatory coverage periods as listed below.  A new waiver is required at every semester unless insurance is waived for the entire academic year.

Request workflow:

  1. Complete the waiver form verifying the requirements before the census date: January 30, 2013.
  2. Bring the waiver form and supporting documents for approval to room 114 in the swift center.
    1. Proof of insurance coverage with insured’s name with beginning and ending dates of coverage. For continuous coverage purposes, the mandatory coverage periods are:
      1. Spring/Summer 2013 : 1/06/2013 - 8/14/2013
    2. Summary of Benefits from insurance that indicate the policy meets the requirements listed below:
      1. Medical benefits of at least $50,000 per person, per accident or illness
      2. A deductible not to exceed $500 per person, per accident or illness
      3. Minimum of $7,500 for repatriation of remains
      4. Minimum of $10,000 for expenses associated with medical evacuation to the home country
      5. Policy plan meets the United States Government's Federal Solvency Guidelines. Foreign companies must state this on the plan or on a separate letter on company letterhead.
If you are not on campus, you can fax. Print the fax cover letter and form below and fax to the number on the fax coversheet. Be sure to include the items listed on the Fax coversheet as noted above.

If you reside outside the DFW metroplex you may refer to the mail-in/mail-out process.

Cost:

Free

Forms/Documents

Please click on the form you need
Fax CoverSheet
Health Insurance Waiver for Spring/Summer 2013