By my signature, I am verifying that I want to purchase the CCU sponsored student health insurance plan, and understand that by signing here, my student account will be charged the cost of the insurance premium. I also understand that as a student in the College of Undergraduate Studies, I will be charged for the student health insurance plan each fall and spring semester until proof of other personal health insurance is presented. If I am in the College of Adult and Graduate Studies I will only
be charged for the semester(s) that I have indicated on this form. This DOES NOT include summer. Students WILL NOT be automatically enrolled in or charged for summer health insurance unless indicated above.