I agree to purchase OSU Student Health Insurance or an equivalent type of health insurance, and to maintain this health insurance in force during my entire tenure in the College of Dentistry. I understand that I may switch from one type of coverage to another at a later time. Additionally, I agree to abide by the requirements of the College of Dentistry and the University Health Service relative to tuberculin testing and other prophylactic procedures and immunizations recommended by the medical staff of the University Health Service.
Type of Insurance requested:
OSU Student Health Insurance
____ Student coverage only
____ Student and Spouse/
____ Student and Child/Children
____ Student and Family (spouse and children)
I have an equivalent policy
Name of company ___________________________
Policy holder _______________________________
You will automatically be billed for OSU health insurance on your fee statement each quarter, unless you notify the College Office of Academic Affairs (see Tammy Lewis), prior to the beginning of the start of each quarter. If you are already covered by a private policy, and you were charged for student health insurance in error, you may delete the student health insurance charge by calling 292-EASE or by deleting the charge on your fee statement when paying fees. Please Note: You must add or drop the charge for the student health insurance by the 14th day after the start of the quarter. Students should examine their quarterly fee statements carefully, to make sure that they have received the insurance coverage (or exemption) as requested.
Signature: ____________________ SSN:________________ Date:_____________
Please return this form by _______________