Waiver of the Claremont Colleges' Health Insurance Plan

for Students with existing Health Insurance

____________________________________________________________________
Student Name

____________________________________________________________________
Name of Policyholder

____________________________________________________________________
Insurance Carrier

____________________________________________________________________
Policy Number or ID number of Policyholder

As the parent of the Harvey Mudd College student listed above, I assure Harvey Mudd College that s/he is covered by adequate medical insurance and, as a result, I will not need the Claremont Colleges' medical insurance plan

____________________________________________________________________
Signature of Student, Parent, or Legal Guardian                                         Date

Please attached a photocopy of your insurance card and return the form by July 9, 2012 to:

Dean of Students Office, 301 Platt Boulevard, Claremont, CA 91711

Or attach this form and a scan of your insurance card in an e-mail to amy_currier@hmc.edu. All questions regarding health insurance should be directed to:

Amy Currier, Administrative Asst. to Dean of Students Office
E-mail: amy_currier@hmc.edu
Phone: (909) 621-8125