LOYOLA UNIVERSTIY
HEALTH INSURANCE ACCEPTANCE / WAIVER FORM
FOR INTERNATIONAL EXCHANGE STUDENTS ONLY
Instructions: All international exchange students who attend Loyola University must show proof of health insurance. Complete Section A if you do not wish to purchase the Loyola University Student Health Insurance. Complete Section B if you do wish to purchase Loyola’s health insurance plan. Loyola University will not issue an I-20 student visa form unless this form and necessary documentation is received along with the application. PLEASE PRINT CLEARLY.
Return this form with your completed Loyola University Application for admission to: Carrie Hogue / Office of International Programs / Loyola University / 4501 North Charles Street / Baltimore, MD 21210 / USA
ALL STUDENTS COMPLETE THIS SECTION:
Student Name_______________________________________________________________________________________ Last Name First Name Middle Initial
Phone Number 011-_________________________________ Email ____________________________________
Country Code City Code Home Number
SECTION A:
Name of Insurance Company/Group Plan__________________________________________________________________
Policy Number_____________________________________________ Expiration Date_____________________
I hereby testify that this insurance policy fulfills the following conditions:
q (a) It provides at least $50,000 per illness or accident per year in coverage;
q (b) The deductible does not exceed $500.00 per accident or illness;
q (c) The policy is valid until January 1, 2010 if I will be attending classes in the Fall semester and/or until August 15, 2010 if I will be attending classes in the Spring semester. If it expires before this date, I will renew the policy so as to ensure the continuance of health insurance coverage for the full academic year. My signature on this form indicates agreement to this condition.
q (d) The cost of medical evacuation ($10,000) and repatriation ($7,500) are included
Student Signature______________________________________________ Date______________________________
Parent/Guardian/Sponsor Signature________________________________ Date______________________________
(If student is under the age of 18 years.)
SECTION B:
Please enroll me in the Loyola University Health Plan for the semester(s) that I am attending Loyola University. I understand that my signature authorizes Loyola University to bill me for insurance coverage. I understand that I will be billed and covered for only the semester(s) that I have initialed below. I have read and accept the contents of the enclosed Loyola University Student Health Insurance Plan Brochure.
SPRING 20__________________FALL 20________________ (Please indicate the semester(s) you require insurance.)
Student Signature______________________________________________ Date______________________________
Parent/Guardian/Sponsor Signature________________________________ Date______________________________
(If student is under the age of 18 years.)
Loyola Identification Number____________________________________________________________
(To be filled in by Loyola Official)
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