Health and Dental Plan Opt-out Form The GSA Health and Dental Plan you are eligible for is designed for students’ needs and is able to give you coverage on top of other insurance plans. To decline participation in the plan, please complete the following: Last Name: ____________________ First Name: ____________________ UC ID: ___________ Phone and/or E-mail: _______________________________________ This application is for waiver of extended health and dental benefits for the academic period starting (effective date): Sept Jan May July (circle one) of __________ (year) Check the appropriate: ____ Opt Out Health Portion ($240) _________________________________________ Insurance Company Name and Policy Number ____ Opt Out Dental Portion ($165) _________________________________________ Insurance Company Name and Policy Number *You must provide proof of alternative coverage that states your name and insurance company name (e.g. copy / scan of your benefits card). You can EMAIL, FAX, or drop off in
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