Idaho State University

Student Health Insurance Refund Petition

Return to: 921 S. 8^th, Stop 8375, Pocatello, ID 83209.

This form must be completed by health insurance refund deadline.

Spring, 2010 deadline, January 25, 2009

fax 282-4036

Last Name __________________________ First Name_______________________

Student Identification #__________________________________

Address Where Check Is To Be Sent:

____________________________

Street Address or Box #

City_______________ State_______________ Zip____________________

Phone #

I request a refund of my Student Health Insurance fee. I understand that I must complete this form within the first 10 days of school to get a refund. Failure to complete this form completely will result in a delay in the refund process. In order to get a refund, I understand that I must be covered by another insurance plan. I understand that my policy must adhere to the standards set by Idaho State University (See http://www.isu.edu/stuhlth/insurance/gen.shtml). By completing this form, I agree to allow the Student Health Insurance Coordinator to verify this information.

___________________________________ _______________________________________

Name of Insurance Company/Carrier Phone Number of Insurance Company

___________________________________ ______________________________________

Address of Insurance Company/Carrier City, State Zip

___________________________________ _______________________________________

Primary Policyholder=s Name Individual Subscriber Number

___________________________________ _______________________________________

Policyholder=s Date of Birth Policy/Group No.

___________________________________ _______________________________________

Student=s Signature Date