Health Insurance Form

A charge has been assessed to your account for sickness medical coverage.  This insurance is required of all full-time students and part-time health professional students.  The charge for the sickness insurance may be waived with proof of alternate coverage at the time of tuition payment.

PLEASE CHECK ONE:

|__|  I do not have alternate coverage, therefore I am purchasing the group insurance provided through CCM.
       Or, I am purchasing the insurance in addition to other coverage.
        I UNDERSTAND THIS PREMIUM IS NON-REFUNDABLE

OR

|__|  I choose not to purchase the sickness insurance plan offered by CCM because I have comparable health coverage in the following plan:

______________________________   _______________________   ________________________
Name of Insurance Company                     Policy/ID#                                  Name of Subscriber
 

I understand that I am required to maintain health insurance coverage throughout my enrollment.

I CERTIFY ALL STATEMENTS GIVEN ARE TRUE AND ACCURATE.

________________             ___________________________________
DATE                                    SIGNATURE OF STUDENT

This form can be mailed to:
County College of Morris
ATTN:  Bursar Department
214 Center Grove Road
Randolph, NJ 07869