Welcome to The Allen J. Flood Companies, Inc.

	Becoming a Client
	College & University Students
	Student Health Center
	Claim Filing Procedures
	Claim Forms
	Contact Us

Student Waiver Form


1.	Name of School
2.	First Name of Student
	Last Name of Student
3.	Permanent Residence
	Street Address
	Street Address (Suite/Apt Number)
	City
	State
	Zip
4.	Student I.D. Number
Questions #5 through #10 pertain to your personal health insurance plan including a family plan or employer sponsored plan but not the College/University sponsored plan.
5.	Name of Insurance Company
6.	Policy Number
7.	First Name of Policyholder
8.	Last Name of Policyholder
9.	Date of Birth of Policyholder (mm/dd/YYYY)
10.	Relationship to Policyholder

11.	Student Classification
12.	Coverage Type
13.	Coverage Term:
14.	Waiver Deadline Date
	Email:
Please Note: The College/University reserves the right to request in writing evidence of annual health insurance coverage. Evidence of such coverage can be furnished by submitting one of the following: the front and back of a health insurance identification card, a copy of the insurance policy or a letter from the insurance company confirming coverage is in effect during your period of enrollment.

Student Waiver Form