PROOF OF MEDICAL INSURANCE FORM
2009 CIC Latin American Health, Nutrition and Environmental Issues Program in the Dominican Republic
You are required to have medical/health insurance while studying abroad. You should check with your current policyholder to confirm whether or not you will be covered during your stay in the Dominican Republic. If you do not have medical/health insurance, or if your current policy will not cover you abroad, you will need to purchase insurance with adequate coverage throughout the duration of the program. There are several insurance companies that offer special international policies for students studying abroad. A basic plan can be expected to cost about $40 a month and will cover you only while you are outside of the United States. Check with your campus study abroad office or student health center for referrals to specific companies. Please provide us with proof that you are covered by medical/health insurance. We will need the following information: Name of Insurance Company: ______________________________ Telephone Number of Insurance Company:____________________ Policy Number:________________________________________ Your signature confirming that: you will be covered from 8/11/09 through 12/07/09 that this coverage includes medical treatment received while abroad
(Your printed name and signature) Please submit this information by May 15. Students who do not submit proof of adequate coverage by this date may be required to purchase a policy chosen by the program administrators in order to participate in the CIC Dominican Republic program.