Graduate Assistant/Associate
Health Insurance Declination Form
Declination Forms should be submitted to
University Health Services insurance office within thirty days of your initial
eligibility date.
Name: (Please Print)___________________________________________________________
Address1:________________________________________________________
City, State, zip:_____________________________________________________
CWID#:____________________________
Office phone ___________________________
Home phone ___________________________
Email:
_______________________________________________
I certify that I am declining insurance
coverage through the Oklahoma State University Graduate Assistant/Associate plan
provided to teaching, research and graduate assistants and associates. I
understand that this declination also eliminates spouse and/or dependent
eligibility through this plan. If I choose to accept this policy in the future,
coverage will not be available until the first day of the semester following
that decision. I understand that this declination will remain in force until
rescinded in writing and submitted to the University Health Services insurance
office.
______________________________________________________________________
Signature Date
Please return completed form to: Oklahoma State University
University
Health Services Insurance Office