The effective date of the insurance policy must be included. ▫ Each policy form must have a unique form number in the lower left‐hand corner of the first page.In order to avoid a lapse in coverage, this petition must be received within 31 days of your last day of coverage. The deadline to submit a Petition to Waive for any 2023-24 coverage period is pm EST on August 12, 2024. Be sure to include your Insurance Information Exchange Account Number. • Fill in the following blocks in Part A: Name, address, city, state, zip code, company,. Complete Orientation. 4. Health Insurance: Carrying Health Insurance is mandatory. Will the Student Health Benefits Plan cover me when I'm out of the country? 2) Print and complete the appropriate form(s) in the next section (dependent or independent) that pertain to your special circumstances.