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									STUDENT/SCHOLAR Name                           POLICY NUMBER




Updated: 1/22/2005 (PAGE 1 of 6)
AUBURN UNIVERSITY HEALTH AND EMERGENCY ASSISTANCE
INSURANCE REQUIREMENTS OF SPONSORED NON-IMMIGRANT STUDENTS AND SCHOLARS
          Effective August 1, 2002, Auburn University implemented a mandatory major health and emergency assistance insurance
requirement for ALL non-immigrant students and scholars in F-1/J-1 status (including accompanying dependents) enrolled at Auburn
University. Due to the increasing costs and complexity of the US health care system and potential disastrous effects on our foreign
students and scholars the AU Board of Trustees and AU administrations has approved the implementation of this requirement.
Furthermore, according to a 1986 United States Court of Appeals for the Sixth Circuit decision, policies such as this one that seek "to
protect students' ability to exist in the community, taking cognizance of the high costs of health care in this country” are “consistent
with the purposes of federal immigration law”. "The federal policy requires that these students be financially responsible: the
institution which the student will attend must certify that the student is entering this country with sufficient financial resources to meet
all of his or her anticipated expenses. The requirement that this group of students maintain health insurance furthers the federal policy
requiring their financial responsibility. The policy furthers the legitimate state end of preventing catastrophic harm to students. It
furthers the federal policy of assuring the F-1 visa holders are financially responsible." All participants in AU certified programs have
medical insurance premium costs calculated into the cost of attendance for Auburn University and specifically appear on the I-20
documents and are included for issuance of the DS-2019 certificates of eligibility. Furthermore all individuals certify their awareness
of AU policy by accepting their I-20 or DS-2019. For additional information go to: http://www.auburn.edu/aub-ie/insurance
         As Auburn University recognizes the special relationship between foreign and US government agencies and their sponsored
students and scholars the following waiver conditions will only be applied to this special category of students and scholars. Attached
is a copy of the general waiver form, which includes the benefits provided through the AU group plan. Please review and complete
this form and return it prior to the arrival of the student or scholar or at the latest prior to the first day of classes each semester so that
we may appropriately evaluate the coverage/support provided. NOTE: Do NOT use the USDOS suggested minimum standards as
the baseline, the AU plan meets US DOS standards and has been adjusted to reflect present day increased minimum health care
standards for insurance at both the national and local levels.

We hereby certify that we as sponsors of the below named individual student/scholar and dependents will guarantee that in the event
of a health care difficulties or emergency we will be responsible for providing ALL assistance required by our sponsored
student/scholar and any accompanying dependents. We recognize that our health insurance policy (CHECK ONE):

         Is EQUAL TO OR GREATER THAN in coverage than the AU policy
         Is NOT equal to or greater than the AU policy, HOWEVER in the event of a health care emergency we will ensure that the
         individual and dependents involved will not require public assistance or other financial assistance from US institutions or
         agencies to remain in the US. All health care costs will be covered by our organization in the absence of the individual and
         or dependents being unable to cover said expenses.
NOTE: STUDENTS AND SCHOLARS WILL BE BILLED AUTOMATICALLY FOR COVERAGE UPON ARRIVAL OR
ENROLLMENT UNTIL THE WAIVER REQUEST IS REVIEWED. SCHOLARS ARE ULTIMATELY RESPONSIBLE
FOR PAYMENT OF ALL DEBTS IN THE EVENT OF THE SPONSOR WITHDRAWING SUPPORT.
We therefore request that Auburn University WAIVE -     NOT WAIVE the health and emergency assistance insurance
FOR      Fall-    Spring -   Summer SEMESTER -Year            (i.e.: 2004, etc.)
This form must be submitted to OIE by:     4:00pm CST, First day of the program/class; every AU semester.
Name of student/scholar                                               Passport Number
Number of dependents     Accompanied by Spouse –              Yes     No             Number of Children:
Name of SPONSORING agency
Agency Representative Signature:                                                                                     Date:
Printed Name:
TITLE:
Address
City/State/Country
Phone Number                                                                    Email:

     Page 1 of 6 – Auburn University - SPONSORED NONIMMIGRANT HEALTH INSURANCE WAIVER REQUEST FORM – version 1/20/2005
STUDENT/SCHOLAR Name                     POLICY NUMBER




Revision: 1/20/05 (SPONSORED – PAGE 2 of 6)

WAIVER REQUEST FORM FOR: NON-IMMIGRANT INTERNATIONAL STUDENTS AND
SCHOLAR HEALTH AND EMERGENCY ASSISTANCE INSURANCE PROGRAM (NON-SPONSORED
STUDENTS AND SCHOLARS FORM) – COMPLETION AND SUBMISSION OF THIS FORM DOES NOT GUARANTEE A
WAIVER FROM THE MANDATORY AU REQUIREMENT, ALL SUBMISSIONS RECEIVED BY THE DEADLINES
INDICATED BELOW WILL BE REVIEWED AND YOU WILL BE NOTIFIED OF THE FINAL DECISION.

Note: If you are SPONSORED by a foreign government or related governmental agency, please use the Waiver form for
Sponsored Students and Scholars. For additional information go to: http://www.auburn.edu/aub-ie/insurance

INSTRUCTIONS: Please read, fill in and sign on Page 2 and submit this entire package (including Pages 1/2) to
your insurance company to be completed. Your insurance company must send this package back to the Office of
International Education, Auburn University, prior to the deadline date and time.

PAGE 1 OF 5 - “I hereby request that Auburn University waive the mandatory health and emergency assistance
insurance requirement based on the information provided on this form by my insurance company.

WAIVER REQUEST IS FOR          Fall-   Spring -  Summer SEMESTER -Year            (i.e.: 2004, etc.)
This form must be submitted to OIE by:   4:00pm CST, First day of the program/class; every AU semester.

COMPLETE THIS INFO BOX (Needed by your insurance company to complete the waiver form attached):
     PRINT or TYPE LEGIBLY – if we cannot read the information your request will NOT be considered
ID Number (Student/Scholar AU ID #):

SCHOLAR/STUDENT NAME:
PLEASE IDENTIFY HOW MANY DEPENDENTS                  SPOUSE   NO - YES;
ARE ON YOUR VISA STATUS:                             CHILDREN: NO -  YES; how many children
STREET ADDRESS:

Street address(continued):

CITY:                         STATE:                      ZIP/POSTAL CODE                  COUNTRY:
PHONE:                        FAX:                        EMAIL:
POLICY HOLDER NAME ON INSURANCE POLICY:
NUMBER OF DEPENDENTS COVERED BY THIS POLICY: #
INSURANCE CO. NAME:
POLICY #:
POLICY EXPIRATION DATE:
U.S. CLAIMS OFFICE
NAME (Required):

ADDRESS (Required):

CITY/STATE (Required):

U.S. CLAIMS PHONE # (Required):
U.S. CLAIMS FAX (Optional):

 Page 2 of 6 – Auburn University - SPONSORED NONIMMIGRANT HEALTH INSURANCE WAIVER REQUEST FORM – version 1/20/2005
STUDENT/SCHOLAR Name                    POLICY NUMBER



STATEMENT ON “EQUAL TO OR GREATER THAN”: AU automatically enrolls all international students,
scholars and their dependents in a mandatory health and emergency assistance insurance program from the day
they enter the US on their program until their departure. Waivers of this requirement must be presented prior
to arrival or at the latest at the time the student or scholar reports in to begin their program. Waiver
requests received following arrival and no later than two weeks following reporting in will result in the automatic
billing of the insurance premium. Should a waiver be granted during this period the student or scholar will be
required to pay at a minimum one months health insurance premium.

For waiver purposes the student or scholar must provide from their insurance company a completed waiver form
that meets the EQUAL TO or GREATER THAN standard.

DEFINITIONS:

EQUAL TO: means that the proposed insurance provides at a minimum the same benefits as those provided under
the AU policy. This means equal to ALL benefits listed on the waiver form and not just selected benefits.

GREATER THAN: means that the proposed insurance provides for benefits that are greater in coverage than those
provided under the AU plan.

EQUAL TO OR GREATER THAN: means that the proposed insurance plan provides for some benefits that are
EQUAL TO and others that are GREATER THAN. There are NO benefits on the proposed plan that are LESS than
those provided by the AU plan.

The ENTIRETY of the plan as outlined on the waiver form must be considered. If the proposed plan has specific
benefits which are NOT equal to or greater than the AU benefits, the proposed plan is NOT equal to or greater than
the AU policy regardless of whether the proposed policy has some benefits which are better than those offered by
AU. Only those benefits outlined on the AU plan are considered, if the proposed plan has other benefits which are
not included in the AU plan those benefits are NOT considered as part of the waiver review.

For example the AU policy has special arrangements with the insurance vendor to remove any exclusions
associated with self inflicted injury or alcohol abuse that are associated with the emergency assistance, medical
evacuation and repatriation component of the insurance plan. MANY insurance plans exclude coverage for
emergency assistance AND all other medical services under these conditions. AU has negotiated this support
specifically for the EMERGENCY ASSISTANCE component only. This is a KEY management and SUPPORT
element. If the proposed plan has exclusions for such support then the proposed insurance program is “LESS
THAN” the AU program in its benefits plan. Additionally the AU plan includes a mental health component and
significant benefits that are in compliance with suggested standards identified by the US Department of State
regulations for health insurance.

This MANDATORY AU International Student and Scholar Health plan meets present day US and local health care
standards as recommended by the AU International Advisory Council Insurance Committee and approved by the
Auburn University Board of Trustees.

Student/ Scholar Signature Required: I have read this Waiver Form and hereby authorize the above named
insurance company to release the following information directly to Auburn University. By signing this document I
understand the conditions and requirements of the waiver process. I further understand that forms received after the
deadline and/or INCOMPLETE FORMS will result in a denial of the request.

Student/Scholar SIGNATURE:_______________________________________________Date:

Print Student/ Scholar Name:_

FOR OIE OFFICE USE ONLY                 DATE REQUEST RECEIVED
DECISION           APPROVED                                                     DENIED
REVIEWER INITIALS:                      REVIEWER INITIALS:                      DATE
COMMENTS:


 Page 3 of 6 – Auburn University - SPONSORED NONIMMIGRANT HEALTH INSURANCE WAIVER REQUEST FORM – version 1/20/2005
STUDENT/SCHOLAR Name                           POLICY NUMBER




THIS SECTION TO BE COMPLETED BY THE INSURANCE COMPANY REPRESENTATIVES:
           COMPANY REPRESENTATIVE Please respond to the following based on policy coverage:
Are the benefits of your policy “Less than”, “Equal to” or “Greater Than” the




                                                                                                                     Not covered




                                                                                                                                                          Great than
                                                                                                                                   Less than

                                                                                                                                               Equal to
following AU policy benefits listed below? PLEASE CHECK the appropriate response for each
item below in the “Less than”, “Equal to” or “Greater Than” columns

1       Is the policy underwriter or insurance company licensed to do business in the state of Alabama.
2       Is the policy rated “A” by the AM Best Rating Company?
3       Is the participant provided with a permanent ID card for Major Medical policy?
4       OPTIONAL: Is the participant provided with a permanent and separate ID card for Emergency




                                                                                                                     Optional

                                                                                                                                   Optional

                                                                                                                                               Optional

                                                                                                                                                          Optional
        Assistance coverage?


5       Are claims paid within 13 to 20 working days of submission? If necessary, a request for additional
        information either from the student, scholar or medical provider must be sent by the contractor within 13-
        20 business days of receipt of the claim. Is this a condition of the plan?
Emergency Medical Assistance Program (EMAP)
6       Does this policy have an Emergency Assistance Program Call Center?: includes access to a 24 hour/7
        days a week worldwide emergency assistance service call center. Participants are provided with a listing
        of telephone numbers (toll free) by country.
7       Does this policy provide for Medical Evacuation in an amount $150,000 or more per insured? Ground
        and Air Ambulance service and all coordination of transportation must be included.
8       Does this policy provide for $25,000 Repatriation or Remains Coverage?: Includes the payment for
        preparation of mortal remains, cost involved with shipment and funeral directors expense, as well as
        coordination of transportation of the body to their place of residence in their home country.
9       Family Assistance Benefit: in the event that the insured participant or spouse requires hospitalization
        exceeding 7 days or in the event of the death of the participant , the company will pay the roundtrip
        airfare and up to $1,000 for room and board expenses for one family member (mother, father, brother,
        sister, spouse, son or daughter). All expenses must be approved by the contractor.
10      Is there a reunification benefit? In the event of the death insured mother, father, brother or sister, the




                                                                                                                     Optional

                                                                                                                                   Optional

                                                                                                                                               Optional

                                                                                                                                                          Optional
        contractor will pay up to $750 towards the cost of an airline ticket for the insured to return for a home
        visit.

11      Does this policy provide assistance for “other services”, such as Lost Document Assistance, Legal

                                                                                                                     Optional

                                                                                                                                   Optional

                                                                                                                                               Optional

                                                                                                                                                          Optional
        Referral, Consulate Contacts, Hospital Deposit guarantees, Locator Service for Medical services and
        Specialties, Emergency Message Transmission Service, Referral to Interpreters and Emergency Cash
        Advances?
12      Are the services under this benefit EXEMPT from the overall policy exclusion provisions related to self-
        inflicted injuries, suicide and the use of alcohol/intoxication?
Major Medical Coverage
13      Is the Copay: $25 per outpatient physicians visit or less?
14      Is the Hospital Emergency Room Co-pay: $75 per visit or less?
15      Is the Deductible: $200 per coverage year or less?
16      Is the Maximum benefit amount $250,000 per accident or illness or greater?
17      Are usual, reasonable and customary (URC) charges paid at least at the 90th percentile of the Medical
        Data Research Values and adjusted semi-annually?
18      Is 100% of coverage paid, after co-pay, if use an Approved Provider such as AU Medical Clinic
        operate by the East Alabama Medical Center Health Foundation?
19      Is the Major Medical Benefits: 80% for first $5,000; 100% from $5,001- $250,000 or greater for use of
        Non Approved Providers?




     Page 4 of 6 – Auburn University - SPONSORED NONIMMIGRANT HEALTH INSURANCE WAIVER REQUEST FORM – version 1/20/2005
STUDENT/SCHOLAR Name                           POLICY NUMBER




THIS SECTION TO BE COMPLETED BY THE INSURANCE COMPANY REPRESENTATIVES:
           COMPANY REPRESENTATIVE Please respond to the following based on policy coverage:
Are the benefits of your policy “Less than”, “Equal to” or “Greater Than” the




                                                                                                                                                            Greater Than
following AU policy benefits listed below? PLEASE CHECK the appropriate response for each




                                                                                                                       Not covered

                                                                                                                                     Less Than

                                                                                                                                                 Equal to
item below in the “Less than”, “Equal to” or “Greater Than” columns



20      Is the Prescription benefit based on a $20 Copay or less with no cap or limit? Inclusions: Drugs and
        medicines dispensed by a pharmacist on written prescription including birth control and emergency
        contraception?
21      Does coverage provide for Hospital room and board at the semi-private rate?
22      Is there URC coverage for hospital services and supplies (including but not limited to the cost of the
        operating room; laboratory tests; x-rays examinations; anesthesia; drugs – excluding take home drugs or
        medications; therapeutic services; supplies; chemotherapy; radiation therapy; ER; intensive care; critical
        care; surgery; and other prescribed service)? (Please explanation of any limitations to coverage)
23      Is there URC coverage for physician, surgeon, anesthetist, radiologist, registered nurse or physiotherapist
        fees? (Please attach explanation of any limitations to coverage)
24      Is there coverage for Blood, plasma, oxygen, artificial limbs and eyes, casts, splints, trusses, braces, and
        crutches? (Please attach explanation of any limitations to coverage)
25      Are expenses for outpatient surgery, services and expenses including emergency room, trauma center,
        physician office, outpatient surgery centers and ambulatory surgery centers covered in the same manner
        as inpatient? (Please attach explanation of any limitations to coverage)
26      Are expenses incurred for miscellaneous outpatient services including diagnostic x-ray services and
        laboratory procedures when prescribed by the attending physician and when followed by medical
        treatment covered in the same manner as inpatient? (Please attach explanation of any limitations to
        coverage)
27      Are Rental charges for wheelchair, hospital bed, or other special mechanical equipment to facilitate care
        or treatment covered? (Please attach explanation of any limitations to coverage)
28      Are the costs for ambulance services covered? (Please attach explanation of any limitations to coverage)
29      Are Home health care benefits covered as required by Alabama State Insurance Law?
30      Are Mammography benefits covered as required by Alabama State Insurance Law?
31      Is there outpatient treatment for alcohol or substance abuse for 30 visits or more per year up to a
        maximum of $100 per visit per policy year?
32      Is inpatient emotional or mental disorders coverage payable at 100%? and for up to 30 days per coverage
        year?
33      For maternity and newborn care, are hospital confinement, surgical benefits and care covered on a URC
        basis? Newborn infants must be enrolled in a dependent or other policy within 31 days of birth.
34      Are voluntary abortion benefits covered?
                                                                                                                       Optional

                                                                                                                                     Optional

                                                                                                                                                 Optional


35      Are there home country benefits for up to 120 days?                                                                                                 Optional
                                                                                                                       Optional

                                                                                                                                     Optional

                                                                                                                                                 Optional

                                                                                                                                                            Optional




36      Are there benefits for covered students and scholars for the diagnosis and treatment of
        intracollegiate/club sport injuries?
37      Is there dental treatment of accidental injury to sound, natural teeth, URC covered?
38      Is there a pre-existing conditions waiting period of 6 months or less following enrollment, for students,
        scholars and dependents in all classes?
        During the six month waiting period is there a maximum of $2,000 or more coverage for pre-existing
        conditions requiring care?
39      Does this policy have Exclusions? PLEASE ATTACH LISTING OF ALL EXCLUSIONS and
        POLICY LIMITING CONDITIONS


     Page 5 of 6 – Auburn University - SPONSORED NONIMMIGRANT HEALTH INSURANCE WAIVER REQUEST FORM – version 1/20/2005
STUDENT/SCHOLAR Name                       POLICY NUMBER



       THIS SECTION TO BE COMPLETED BY THE INSURANCE COMPANY REPRESENTATIVES:
COMPANY REPRESENTATIVE Please respond to the following based on policy coverage:
40      Please identify the EMERGENCY ASSISTANCE COMPANY (for items 6-10 above) and CONTACT INFO
 Name of EMERGENCY
    assistance company
   Address
      City
         State
       Phone #
         Fax #
      E-mail
    Web site
24/7 EMERGENCY ASSISTANCE PHONE NUMBER

41      Please identify you US BASED CLAIMS OFFICE CONTACT INFORMATION
Name of CLAIMS OFFICE IF
DIFFERENT FROM POLICY
     Address

        City
       State
     Phone #
       Fax #
    E-mail
  Web site
TO BE SIGNED BY INSURANCE COMPANY OFFICIAL AND SUBMITTED DIRECTLY FROM THE COMPANY TO
THE OFFICE OF INTERNATIONAL EDUCATION: I hereby certify that the above named individual carries the identified
insurance plan for the period indicated above and it is currently in effect. In our opinion (PLEASE CHECK ONE BOX):

     I am unable to complete this form as requested.

     NO our policy does NOT provide EQUAL TO OR GREATER coverage as defined on page two

  YES our policy DOES provide coverage THAT IS    EQUAL TO,                    GREATER THAN,          EQUAL TO OR
GREATER THAN as defined on page two of this document

   I am aware that the above named individual is required to verify continuous coverage each semester s/he is
enrolled at Auburn University.
REMARKS OR COMMENTS:


COMPANY NAME
Telephone number
Email address
         Signature
PRINTED NAME
               TITLE
                 Date
     THIS ORIGINAL SIGNED DOCUMENT MUST BE RETURNED TO THE OFFICE OF INTERNATIONAL EDUCATION,
          AUBURN UNIVERSITY, 201 HARGIS HALL, AUBURN, ALABAMA, 36849-5159, PRIOR TO THE DEADLINE

                        Advance copies may be FAXED to: 334-844-4983, email intledu@auburn.edu
     Page 6 of 6 – Auburn University - SPONSORED NONIMMIGRANT HEALTH INSURANCE WAIVER REQUEST FORM – version 1/20/2005

								
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