Student Health
Insurance Waiver/ Compliance Form
921 S. 8th, Stop 8375
(208) 282-2972
Fax (208) 282-4036
Student’s Name: ____________________________Student’s Date of
Birth:____________________
ISU Student ID #______________________ Primary Policy Holder’s
Name:____________________
Policy Holder Date of
Birth:______________ Policy Number:_______________________________
Individual Subscriber #___________________
Insurance Company: _____________________ Insurance Phone
Number:____________________
Insurance Company
Address:______________________________________________________
If you are an international student, stop- this form does not apply to
you.
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 per accident or illness (to include maternity
coverage for policy holders);
_____2. a
deductible not to exceed $2,000.00 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. insurance
company that is owned, operated and based in the United States in compliance
with applicable federal laws; and
_____5. health
insurance in force and maintained for the full academic year.
I
further understand that:
a.
Idaho State
University (ISU) requires Insured as a 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