Test Form – EIIA Member Portal

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If you are insured individually or through one of your parents, you may elect to waive the insurance coverage offered by your institution. You must provide ALL of the necessary information below and answer the questions to successfully waive this coverage. Your primary insurance coverage must cover you throughout the entire academic year and exceed or be comparable to the benefits provided under this plan. Please have the following information available:

Student Information (including your student ID number)
Policyholder’s information, if it is not you (name and telephone number)
Insurance company information (name, phone number and ID number)

PRIVACY POLICY: The personally identifiable information that you provide through this secure website is made available only to authorized agents of your institution and EIIA for a period of one (1) year. If you need to change any previously submitted waiver information, please contact us for assistance.

Terms & Conditions Statement (w/ checkbox): I have reviewed the brochure and understand that by waiving this coverage I am financially responsible for any medical charges. I also acknowledge that I cannot opt-in to this plan unless I involuntarily lose coverage.

First Name *

Last Name *

Student ID Number *

Confirm Student ID Number *

Student ID Photo

Accepted file types: jpg, pdf, png, Max. file size: 2 MB.

Date of Birth *

Resident or Home State *

Policy Holder Last Name *

Policy Holder First Name *

Insurance Company Name *

Insurance Company Phone Number *

Insurance Company ID Number

Medicaid

Yes

OUT OF STATE MEDICAID WILL NOT BE ACCEPTED

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Post Tag

Separate tags with commas

Insurance Coverage

My insurance will cover me (i.e., routine, non-emergency care, as well as emergency care) while I am in City, State (or local area where student will be residing and studying for the academic year).

Yes

Your Email *

Enter Email Confirm Email