Welcome to Aultman College's centralized enrollment, payment, and waiver resource.

Choose the form below to fill out.

Enrollment / Waivers

Students who have other coverage and are waiving out of the Student Health Insurance Plan MUST complete the On-Line Waiver form EVERY semester. The waiver must be completed by the following date:

Summer semester – May 23, 2014

Failure to complete and submit the On-Line Waiver by the semester deadline will result in the full premium payment being charged to your tuition account which you will be responsible for paying.

School Name

Waiver Semester

Student Information

Social Security Number (xxx-xx-xxxx) (You MUST enter either your SSN or I-20 Number below.
If you do NOT have SSN because you're international student, you MUST enter I-20 number)

International Student I-20

First Name

Last Name

Suffix

Date of Birth

Gender

Address Line 1

Address Line 2

City

State

Zip code

County

Contact Phone Number (xxx-xxx-xxxx)

Other Coverage Information

Check All Coverage that Apply Medical Dental Vision RX

Other Insurance Carrier

Benefit Effective Date

Policy Number

Name of Primary Insured

Relation to Primary Insured

Phone Number of Other Carrier (xxx-xxx-xxxx)

I have read and understand the Waiver Insurance requirement and agree to maintain health insurance during my enrollment at this educational institution. I authorize my institution and its representatives to obtain eligibility verification and benefit information as necessary to process this waiver. I fully understand that if my current healthcare coverage becomes terminated, it is my responsibility to immediately advise AultCare Customer Service of my status change. I understand that if I enter any information on this form that is not accurate I will become disqualified to waive the automatic coverage provided by my educational institution. As a result I will be responsible for full premium payment as added to my tuition account.

By entering my name below I acknowledge that the above information is correct. I have read and understand the waiver process as described above.

Form Verification Name Entry

Print a copy of your summary page and waiver confirmation for your records each semester.

Email Address