Medical Insurance Exemption form

Use this form to: Request an exemption from paying your own medical insurance premium effective July 1, 2015.

Name
First Last
Date of Birth
Study
Email*
Enter Email Confirm Email
1.) Are you already paying your own medical insurance premiums?
- Yes, go to question 6
- No, go to question 2
2.) Will you be graduating in July 2015?
- Yes; go to question 5
- No; go to question 3
3.) I would like to request an exemption for:
4.) I will start paying my own medical insurance premium on:
Skip question 5
5.) Please indicate your graduation date:

You will be insured until the date abovementioned.
6.) Declaration and Signature:*
- I declare that, I have completely read the letter from the Minister of Education, Culture, Youth and Sports Affairs dated February 27, 2015 regarding the changes in the collective medical insurance.
You must accept the declaration above in order to complete this application and submit the form!