5071 WEST H AVENUE | KALAMAZOO, MI 49009 | 269.381.6630

1st Agency: Belmont Abbey College Waiver Form

Complete this form ONLY if you have Proof of Alternate Health Insurance. NOTE: Your insurance must be valid and accepted in the Greater Charlotte/Mecklenburg County area. 

Students who have other coverage and are waiving out of the Student Health Insurance Plan MUST complete the online Waiver Form below and include a copy of your insurance card (front and back) by the due date. 

The Waiver must be completed by: 08/21/2020. The opportunity to waive coverage is limited ONLY to students who have other health insurance that is valid in the Greater Charlotte/Mecklenburg County area.


Required items are indicated with an asterisk (*). You MUST click the Submit Button to complete the form.


Student Information

(Jr., Sr., II, III, IV)




Insurance Information
(If unknown, please enter "Unknown")


Insurance Card Upload