Waiver Terms of Agreement
2019-2020 Plan Year
Notification of University Mandate
Georgetown University (GU) requires most full-time students in a degree progam to enroll in the Premier Plan, unless proof of other coverage that meets the University’s requirements is satisfied. The Premier Plan is designed for GU students and a charge for it is placed on eligible students’ accounts.
Eligible students are mandated coverage only once per academic year for their applicable Open Enrollment Rates and Dates (either in the Fall or Spring). Once an eligible student is enrolled, the coverage remains in effect for the remainder of the Plan Year, through 8/14/2020. Prorated refunds are not granted.
Students who apply to waive during the applicable Open Enrollment Period will have the entire student rate refunded on their Student Account, upon approval. Fall annual Plan waivers also apply, as a default, to any 2018-2019 Early Arrival elections in the summer.
Late Enrollment Notification
Only eligible students within 31 days of certain circumstances may purchase the Plan, late, after their applicable Open Enrollment Period.
If you waive coverage in the Fall as an eligible student and become ineligible (reduced credit hours) in the Spring, you do not qualify for Late Enrollment.
E-mail the GU Student Health Insurance Office, firstname.lastname@example.org, to obtain the proper forms, pro-rated premium, and instructions for such mid-year enrollments. Include your GUID# that begins with an “8” in your e-mail.
Student Waiver Agreement
I attest that I have health insurance from another source that meets the University’s waiver requirements. I understand that I MUST have health insurance throughout my academic year. I attest that my health insurance (even if an HMO) will cover most inpatient and outpatient services rendered in the Washington, D.C. metropolitan area. To the extent that my health insurance does not provide coverage for health care expenses I incur, I understand that I am obligated to pay for those services. I understand that the other insurance company’s information indicated in this waiver survey may be given to health care providers upon their request to bill for health care services I obtain, and that Georgetown University Hospital may bill my insurance company for medical services rendered to me.
I understand that the effective date of my other insurance coverage must be on or before the last day of my Open Enrollment Period or if applicable, the date required as an incoming Early Arrival student. I understand that if I do not submit the waiver survey with the requested responses by the last day of my Open Enrollment Period, I will remain enrolled and will be responsible for the Premium charged to my student account for the Premier Plan. If I authorized any providers to send claims to the 2019-2020 Premier Plan for payment prior to the submission of this form, I understand this waiver will be rescinded and I will be responsible to pay the Premium. I also understand if I apply for a waiver after my Open Enrollment Period, a nonrefundable $100 late waiver fee will be applied to my student account and that all waivers are subject to approval by Georgetown University Student Health Insurance.
I understand that the submission of a waiver to Student Health Insurance indicates agreement to the Waiver Terms and Agreement for the 2019-2020 Premier Plan and is applicable to any 2018-2019 Early Arrival coverage for the summer for which I have been mandated and charged. I attest that the information provided to waive the Premier Plan is correct and understand it is subject to Student Health Insurance approval and applicable Student Code of Conduct Provisions.