For emergency reasons, we need to keep your medical insurance information on file.  If you have no insurance please fill in your name below and then for insurance carrier put "none".  If you carry your own insurance, or if you are your parent's dependent and will be listed under their insurance, then please provide us with all of the following information.

Alternately you can print the following form and mail it to us: Print Insurance Form

If you would prefer, you can fax both sides of your insurance card with your student name to the attention of our registrar at: 262-542-3578.

Thanks for your help.