Boise Bible College

Student Information
Student Name * First Last
Who are you? Your name goes here!
Best Contact Number * ### - ### - ####
Your best contact number.
Email *

Your email address.
Health Insurance Information
Boise Bible College (BBC) Health Insurance Policy *
BBC does not offer health insurance or medical assistance to students. BBC students are responsible for securing their own medical treatment and fulfilling incurred fiscal obligations. BBC encourages every student to have an active health insurance policy to help in securing medical treatment and fulfilling payment.

Please read the BBC Health Insurance Policy.
Student Health Insurance Status *
I am covered by an active health insurance policy. I plan to obtain an individual/family health insurance policy. I choose not to obtain health insurance coverage, and I acknowledge that I will be personally responsible for all of my medical expenses.

Please check only one option.
Company Name *

What is the name of your health insurance company?
Policy Number *

What is your policy number?
Some health insurance policies have a group number that is associated with the policy number. If there is a group number associated, please list the group number with the policy number.

Example:
Group Number- #ABC12345 / Policy Number- #AB1234

Example:
Policy Number- #AB1234
What health insurance companies are you exploring?
What date are you expecting to have your health insurance policy secured?
I acknowledge BBC's encouragment for every student to have an active health insurance policy. I acknowledge that I am going against the recommendations of BBC in choosing not to have an active health insurance policy. I acknowledge that I will be fully responsible for all incurred health expenses.
Student Signature and Date
By typing my full name, I am acknowledging:
1) I have read and agree to BBC's health insurance policy,
2) I have accurately provided my health insurance status and information, and
3) I absolve BBC from any responsibility for medical expenses incurred by me due to illness or accident. *

Please read the disclaimer and type your full name in the box provided.
Date signed * MM / DD / YYYY
Please put the date that you signed the form. This should be today's date.
Do Not Fill This Out

Boise Bible College

Student Information

Health Insurance Information

Student Signature and Date