Accident & Sickness Plan Waiver Form

Chowan University Accident & Sickness Plan Waiver Form

Chowan University offers short-term accident and sickness plans for students considered enrolled as full time (undergraduate 12+ credit hours or graduate 6+ credit hours). All traditional undergraduate and residential graduate students are required by school policy to show proof of health insurance coverage to be used in the case of an emergency. The Accident & Sickness Plan coverage begins in mid-August and ends June 1st. If students currently have medical insurance and would like to waive out of the cost and coverage assessed by the University, you must complete the waiver before the deadline.

Complete the form below to provide proof of your current health insurance coverage to prevent being charged for Chowan’s plan.

If you are an athlete seeking insurance to participate in university athletics, please contact Lisa Bland, Head Athletic Trainer, at (252) 398-1694. Please note the Accident & Sickness plan is separate from any needs related to the athletic insurance necessities.

School Year: 2025-26

School Name: Chowan University

Semester Deadlines: TBD

Student Data

First Name *

Middle Name *

Last Name *

Select

Date of Birth *

Month

Day

Year

Student Id Number *

Sex *MaleFemale

Mailing Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Phone Number *

Email Address *

Classification Information:

Academic Division *

Year in School *

Residential Status *

Insurance Information

Insurance Carrier *

Name of Primary Insured *

Date of Birth for Primary Insured *

Month

Day

Year

Policy/Group # *

Student's Relationship to Primary Insured *