Associated Insurance Plans International, Inc.
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Need Assistance? 800-452-5772
 
    DOMINICAN UNIVERSITY    
   

 SPECIAL NOTICE

All full time Students are urged to maintain adequate health insurance coverage, while registered for classes at DOMINICAN UNIVERSITY. If you have existing health insurance coverage or another plan for paying your medical expenses, you must complete the Waiver Form. Please note: Existing Coverage will be verified.

 
 Important Customer Service Contact Information

Your Customer Service Team at Associated Insurance Plans International, Inc can be reached at 800-452-5772. Our telephones are staffed Monday through Friday, 8:00AM to 7:00PM Central Standard Time.

   
Please be sure to provide as much accurate information as possible. Providing false information is considered deceitful. The information you have provided will be verified and submitted to your College or University.


Personal Information:

* ALL Fields Required

DOMINICAN UNIVERSITY

First Name   Last Name   M/F
   
Address:
City   State   Zip
Phone:
- -
E-mail:
College or University Student ID #:
Date of Birth (mm/dd/yyyy):  
 


Insurance Company or Government Plan Information:

Insurance Company or Government Plan
Phone:
--
Address:
City   State   Zip
E-mail (not required) :

Individual Policy
Group Policy (if so, which group?)

MemberID #:   Group or Policy #:
 

My coverage begins on
(mm/dd/yyyy)
  My coverage ends approximately
(mm/dd/yyyy)
 

Primary Insured's Name (if other than self):
First Name   Last Name
 

Primary Insured's
Date of Birth (mm/dd/yyyy):


Waiver Information:

I have health insurance with another carrier and I have provided my Insurance Company's information in the Insurance Company Information section. I do not want to be a member of the Insurance Plan offered by my College/University. I would like to waive out this coverage.

I authorize my schools insurance plan administrator to verify my insurance information.

Print Name Here To Agree:

Waiver Form Sign Date (mm/dd/yyyy):


  Submit
   
 
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Vision &
Pharmacy
 
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Insurance
for Non-Eligible
Students

If you do not meet the Eligibilty Requirements listed in your student insurance program, please consider our Individual Insurance Plans.