Accident & Sickness Waiver Form for International Students

2022-2023 STUDENT ACCIDENT & SICKNESS WAIVER FORM FOR INTERNATIONAL STUDENTS
Complete and return this form to:  International Student Services • 711 E. Boldt Way, SPC 41 • Appleton, WI 54911
Fax:  1‐920‐832‐7026; Email:  internationalhouse@lawrence.edu

Students that have comparable insurance coverage and choose to waive the medical insurance policy offered through Lawrence University must complete this form.  If you do not have comparable insurance coverage or fill out the waiver on time, you will be automatically billed by the school and covered.  THE WAIVER DEADLINE IS JULY 1 EACH YEAR.

Please visit https://www.studentinsurance.com/Client/863 for insurance information or direct any LU health insurance related questions to Wellness Services.

I have the following comparable coverage that will remain in effect throughout the waiver period indicated:

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