The forms on this page are for the current academic year. Please be sure to complete the appropriate form, and attach all required documentation (if applicable) before submitting it to the Insurance Services department. Incomplete forms will not be processed.
Forms can be submitted via email or fax.
Contact information for the Insurance Services department:
Email: insurance@shcs.ucdavis.edu
Fax: (530) 752-7679
These forms are only to be used if the online waiver system is unavailable. Paper waiver applications can take up to 30 days to be processed.
Please attach a copy of your current insurance ID card (both front and back), a copy of your insurance plans summary of benefits, and documentation from your insurance company, dated within the last 30 days, that shows you are currently covered.
Documentation can be in the form of:
Failure to include the appropriate documentation will result in your waiver application not being processed.
The 2022-23 Academic Year UC SHIP Waiver Application forms will be available as of June 1st, 2022.
You are encouraged to use the online waiver portal to submit your waiver application for the upcoming 2022-23 academic year.
Please fill out the appropriate form completely, and attach all required documentation, before submitting it to the Insurance Services office.
UC SHIP Waiver Appeal form - This form is to be used if your waiver application was denied and you are no longer able to access the online waiver site to make corrections or upload additional documentation.
UC SHIP Waiver Cancellation form - This form is to be used if you have an approved waiver on file for the current academic year, but you wish to cancel it and enroll in UC SHIP.
UC SHIP Cancellation and Refund Request form - This form is to be used if you are no longer a UC Davis student (withdrawn, cancelled registration, dismissed, PELP, Filing Fee), and do not wish to be enrolled in UC SHIP for the current term.
UC SHIP Late Waiver Application - This form is to be used when you have missed the posted waiver deadline date. This form must be filled out and submitted along with a completed waiver application and all appropriate documentation. Late waiver applications are subject to a $50 processing fee.
Students who are on PELP or Filing Fee status, or have graduated, can elect to enroll in voluntary UC SHIP coverage for one additional term of coverage.
The forms below show costs and dates of coverage.
Undergraduate Students / Dependents
Graduate Students / Dependents (Quarter)
Graduate Students / Dependents (Semester)
To enroll yourself or a dependent in the voluntary coverage, vist the Voluntary Student/Dependent page.