BSU International Student/Scholar

Health Insurance Waiver Form

1. Policy and Requirements

It is a Bemidji State University policy that all international students and visiting scholars engaged in educational activities are required to purchase the Minnesota State Colleges and Universities international student accident and illness insurance plan unless they can provide written verification that their government or sponsoring agency (US Government, Foreign Government, Embassy) accepts full responsibility for any medical claims that might occur in the United States OR if they have an approved BSU insurance waiver form and demonstrate proof of comparable insurance coverage prior to the waiver deadline. The waiver deadline for the Fall term is July 31 and for the Spring term is December 31.

Please return this completed form with a copy of your proof of insurance to or the International Program Center at Bemidji State University located in Deputy 103, 1500 Birchmont Drive NE, Box 13, Bemidji, MN 56601.

2. Student Information – To be completed by the student

Student Name:______(please print)

Student Date of Birth (MM/DD/YY): ______TECH ID: ______

Student Visa Type F-1 □ J-1 □

Enrollment Dates for Current Academic Year: ______to ______

I understand that if I receive an insurance waiver, I am solely responsible for any medical costs or expenses that I may incur and that BSU is not responsible for such costs.

Student’s Signature:

______Date:______

3. Insurance Policy Information

This section is to be completed by an authorized agent of the insurance company underwriting the medical insurance policy under which the international student is currently enrolled. This section may NOT be completed by the student.

Policy Name/Number:______Group Number:______

Member Name and ID Number: ______

What are the dates of coverage on the current policy? From: ______To: ______

I verify that the student listed on page 1 of this form is covered under this policy while in the United States. Yes ____ No____

Insurance Requirements:

I certify that the insurance policy listed above includes the following:

· Medical benefits of at least $100,000 per accident or illness

· Repatriation of remains in the amount of $25,000

· Expenses associated with the medical evacuation of the student or exchange visitor to his or her home country in the amount of $50,000

· A deductible not to exceed $500 per accident or illness

· Emergency Room Coverage

· Out-of-Area Coverage, which does not require the student to return to the home country for emergency medical treatment

· Medical benefits provided for Illnesses, Injuries and Accidents

· No waiting period for pre-existing conditions or other pre-existing condition requirements

· Policy is underwritten by an insurance corporation having an A.M. Best rating of “A−” or above; a McGraw Hill Financial/Standard & Poor's Claims-paying Ability rating of “A−” or above; a Weiss Research, Inc. rating of “B+” or above; a Fitch Ratings, Inc. rating of “A−” or above; a Moody's Investor Services rating of “A3” or above.

Please complete or attach business card and copy of policy:

Agent Name:______

Title: ______

Insurance Agency Name: ______

Phone: ______

Email: ______

Agent Signature:

______Date:______