International Student Health Insurance
Compliance/Waiver Form
921 S. 8th, Stop 8375,
(208) 282-2972
Fax (208) 282-4036
Insured’s Name:
______________________________________________________________________
(Family or Last
name)
(Given or First name)
ISU Student ID#:______________________________
Insurance Company: ___________________________ Policy
Number:_____________________
Insurance Phone Number:_______________________
Date Coverage Begins: ____ ____
___ Date Coverage
Terminates: ____ ____ ____
Month/Day/Year Month/Day/Year
REPRESENTATION
REGARDING STUDENT’S COVERAGE:
I, the undersigned, warrant
that the insurance policy corresponding to the insured ISU student named above
(“Student”) contains each
corresponding attribute that I have verified by a “√” symbol below:
_____1. medical
benefits of at least $50,000.00 US per accident or illness (to include
maternity paid as any other medical condition);
_____2. a
deductible not to exceed $500.00 US per accident or illness;
_____3. co-payment
for in-network providers not greater than 25 percent with the insurance paying
at least 75 percent of the charges;
_____4. accident
and illness coverage (to include maternity insurance for females);
_____5. repatriation
of remains in the amount of $7,500.00 US (a type of insurance whereby the
deceased is returned to their home country);
_____6. medical
evacuation coverage of at least $10,000.00 US (that pays for the student to
return to their home country if the student is too ill to attend school);
_____7. insurance
company that is owned, operated and based in the
_____8. health
insurance in force and maintained for the full academic year.
I
further understand that:
a.
Idaho State
University (ISU) requires Insured as an international student to purchase the
ISU’s Student Health Insurance (SHIP), unless Insured is eligible for a waiver
as set forth on this document;
b.
Insured must
comply with ISU’s standards for health insurance;
c.
ISU has
discretion – but no duty – to waive this requirement if Insured is covered by other
medical insurance that meets or exceeds each insurance attribute
described above (shown by my “√” symbol);
d.
If Insured’s policy does not fulfill each above-listed requirement, then
ISU’s health insurance waiver is not available to Insured and Insured must
purchase a SHIP policy;
e.
failure to provide accurate information makes Insured being responsible
to purchase the SHIP policy;
f.
if Insured’s
insurance terminates for any reason, Insured must either obtain other insurance
coverage or re-enroll in the SHIP insurance plan; and
g.
if Insured has
already paid for the SHIP and wish to receive a refund, Insured will need to
contact the Student Health Insurance office before the refund deadline.
I
give consent:
a.
for Insured’s
insurance agent to notify ISU if Insured’s purchased insurance expires; and/or
b.
for ISU to
contact Insured’s insurance agent to verify the status of Insured’s insurance
if any question arises about Insured’s coverage.
My
signature below confirms that:
a.
I have carefully
read this document and understand its contents; and
b.
I accept and am
legally bound to each provision in this document.
_______________________________________________ ____________________________________
Signature [Parent/Guardian, if the insured student is a minor] Date