INDIANA UNIVERSITY SOUTH BEND INTERNATIONAL STUDENT HEALTH INSURANCE

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					         INDIANA UNIVERSITY SOUTH BEND INTERNATIONAL STUDENT
                   HEALTH INSURANCE WAIVER REQUEST
Section I: Student Information (To be completed by Student)

Student Name: Last: _____________________________________ First: ____________________________

Signature _____________________________________________ Telephone: ________________________

Student ID Number: _______________________

Student Street Address:____________________________________________________________________

City: ___________________________________ State: _________________ Postal Code: ______________

Visa Type: ____________________ Student Signature __________________________________________

A copy of your insurance ID card and insurance policy must be attached to this form.

Section II: Insurance Information (To be completed by Foreign Insurance Company Representative)

Name of Insurance Company: _______________________________________________________________

Policy Number: ______________________________________ Country: ____________________________

Effective Date: __________________________                        Expiration Date: _________________________

Coverage Requirements:_________________________ *Your Company’s Benefits_________________

$50,000.00 for each sickness or illness……………………________________________________________

Maternity Benefits: same as sickness; pregnancy
childbirth, and complications……………………………..________________________________________

$50,000.00 for each accident or injury……………………________________________________________

$10,000.00 medical evacuation to home country…………________________________________________

$7,500.00 repatriation of remains to home country……….________________________________________

Deductible (or excess fee) not more than $500.00
Per sickness or injury (per person)……………………….._________________________________________

$500,000.00 Lifetime policy maximum (recommended)..._________________________________________
*Benefits must be covered to give amounts in U.S. Dollars
*Exclusions and limitations must be more than comparable
*Final decisions and approvals are made by Office of International Student Services

_________________________________________                      _________________________________________
Authorized Signature                                           Title/Company

Please return completed form to:         Office of International Student Services, A166X   Office Use Only:
                                         Indiana University South Bend                     Date Received: _____________
        Telephone: 574-520-4419          1700 Mishawaka Ave., P.O. Box 7111                Approval: _________________
        Fax:       574-520-4590          South Bend, IN 46634-7111                         Reviewed by: ______________