Student Health Insurance Program

Temple University Student Health Insurance Program Waiver of Insurance and Certification of Health Insurance Coverage Temple University requires that all International (F1 and J1 visa status) students maintain adequate health insurance coverage at all times while a Temple University student. Health Insurance is available through Temple University and is administered by Independence Blue Cross. The minimum health insurance coverage as determined by the Department of State is:

. A maximum deductible of U.S. $500 per accident or illness . Payment of at least 75% of covered expenses . Medical benefits of at least U.S. $100,000 per accident or illness . Repatriation benefits of at least U.S. $25,000 . Medical evacuation benefits of at least U.S. $50,000

Certification of Health Insurance Coverage I hereby waive my opportunity to participate in the Temple University Student Health Insurance Plan. I also certify that I have coverage by an adequate outside health insurance under the policy noted below.

PLEASE PRINT

*TUid#:

*Name: *Class of: (Last) (First) (M.I)

*Date of Birth:

*Address: ______(Number) (Street) (City) (State) (Zip)

*Status (Check One) Single Married

* * ______Name of Insurance Company City State Zip Code

*Insurance I.D. # *Group #

Name of policyholder if other than yourself:

Relationship to you: Spouse Parent Guardian Other

If other specify: ______*Should this outside coverage cease for any reason, I will immediately obtain other adequate outside health insurance, or enroll in the Temple University Student Health Insurance Plan.* By submitting this form, you are representing that you understand and agree to abide by this requirement. Failure to do so would constitute a violation of Temple University policy. By submitting this form, you are representing that all of the information above is true and correct. You understand and acknowledge that the submission of false information to Temple University is a violation of its student Code of Conduct and may subject you to discipline up to and including expulsion from Temple University.

I accept these terms:

2015 to 2016 *Signature: ______*Date: ______

2015 to 2016