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Get I Have Selected The Following Health Insurance Plan

SBC) Other (Enter Provider Name Here) Type: Full Travel Only Policy#: Effective Date: Student s MBTS ID#: Birthdate: / / Last Name: First Name: Telephone: MBTS Email: Signature: Submit a copy of your insurance card or proof of enrollment with this form to cmack mbts.edu or Fax to: 816-414-3863 Insurance Waiver I have not selected an insurance plan and accept full responsibility for this decision: Signature: 1 IMPORTANT NOTE.

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