This document is a waiver request form containing personal information about an enrollee named Milo Lor Vue. It includes his birthdate, gender, address, email, phone number, class year, insurance group name and number, insurance company name, policy number, and insurance company address. The form also notes whether he will maintain insurance and study program status while attending school.

1. Waiver Request CompletePrivacy Policy Help <br />Complete Please print this page for your records then click the Logout button below. Transaction Number 388227Completion Date 7/13/2010 5:07:06 PM Enrollee Information First NameMILast NameLor VueBirth DateGender1/20/1990MaleAddress While Attending SchoolAddress1Address2CityStateZip1347 Ames AveSt. PaulMN55106Email AddressPhone NumberClass Yearvuel@carleton.edu651-500-54082012Other Insurance Information Group NameGroup NumberUcare00050079700Name of Insurance CompanyPolicy NumberUcare01080081Address1Address2CityStateZip500 Stinson Boulevard N.E.MinneapolisMN55413Maintain InsuranceStudy ProgramYesNo <br />