Document Sample

Return to: Registrar’s Office, Room 11, St. James, by: December 1, 2009.
The personal information collected on this form is collected under the authority of the University of Western Ontario Act, 1982, as amended, and
is used to confirm that participants have health insurance and identify participants who opt out of the USC Health Plan. Certain information will
be sent to the USC. Please direct questions about this collection, use, or disclosure of personal information to the International Exchange
Coordinator, Student Development Services, The University of Western Ontario, London, ON, N6A 3K7, tel: 661-2111, ext. 81156.

NAME:_____________________________                                 STUDENT NUMBER:_____________________

HOST UNIVERSITY:____________________________________________________

TERM(S):___________________________                                 YEAR:________________________

It is your responsibility to ensure that you have adequate health insurance and medical coverage prior to leaving
Canada. All Brescia students are covered by the Ontario Health Insurance Plan (OHIP), another provincial health
plan, or University Health Insurance Plan (UHIP). Please select the provincial plan that applies to you:

□ Ontario Health Insurance Plan (OHIP)
□ Other provincial health plan
□ University Health Insurance Plan (UHIP)

Medical situations may arise in other countries which are not covered by your provincial plan. For this reason,
additional health insurance is required. The UWO University Students’ Council provides supplementary coverage to
Western and affiliate students through the USC Health Plan. Enrollment in this plan is automatic. However, you may
opt out by providing proof of duplicate coverage. To determine whether this particular plan meets your needs,
please read the USC Health Plan brochure closely and contact the Info-Source if you have any questions. You
should also consult the web site at

Please fill out ONE of the statements below. Sign Statement #1 if you WILL be covered by the USC Health
Plan. Sign Statement #2 if you will be WAIVING the coverage offered by the USC though the Health Plan.

Statement #1:

I will be enrolled in the USC Health Plan for the duration of my exchange term(s) as indicated above. I have
carefully researched the out-of-country coverage provided by this plan, including the services, exclusions,
restrictions and limits specified in its terms.

Signature____________________________________ Date_______________________

                                                                 Page 1 of 2
                                   Brescia Exchange Health Insurance Form

Statement #2:

I hereby decline the USC Health Plan offered by the University Students’ Council of The University of Western
Ontario. I have selected the following health insurance plan after carefully researching their out-of- country

Insurance Company Name:____________________________________________________

Policy Number:___________________________ Certificate/Identification#:_______________

Signature____________________________________ Date__________________________