Health Insurance Form For F-1 International Students - University Of Hawaii At Hilo Page 2
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1
2UNIVERSITY OF HAWAII AT HILO
F-1 STUDENT HEALTH INSURANCE FORM
SECTION A
_______________________________________
_______________________________
Last Name, First Name
UH Student ID #
_________________________________
Name of all F-2 Dependents covered under this plan (leave blank if none):
I acknowledge that University of Hawaii (UH) policy requires international students to have health insurance for every term I
am enrolled at the University. If I choose a health insurance plan other than the University student health insurance plan, I
agree to obtain the insurance company’s certification that the plan meets the University’s minimum requirements.
________________________________________________
_____________________________
Student Signature
Date
SECTION B (Check one)
☐ I will purchase the University of Hawaii student health insurance plan. If you will purchase the University of
Hawaii student health insurance plan, attach a copy of your receipt with this form.
☐ I will purchase a different health insurance plan.
SECTION C
This section below must be completed by the health insurance company if you will NOT be purchasing
the University of Hawaii student health insurance plan.
Name(s) of insured individual(s):
_________________________________________
___________________________________
Dependent’s name (if any)
)
Student’s name (please print
Health Insurance Company: ____________________________________________________________
Policy Number/Plan Type: ____________________________
Coverage Period: From: __________________ (mm/dd/yyyy) to _________________ (mm/dd/yyyy)
While enrolled at the University of Hawaii at Hilo, international students are required to have health insurance that
meets ALL of the following minimum coverage requirements (all amounts are in USD). Vision and dental coverage is
not required. Health insurance company: Initial each line below to verify all coverage requirements.
____ Comprehensive medical coverage = at least $100,000 US per accident/illness
____ In-patient/Out-patient medical (including mental health) coverage at no less than 75% usual/
customary charge
____ Repatriation coverage = at least $25,000 US
____ Medical evacuation coverage to home country = at least $10,000 US
____ No more than $500 US deductible per accident or illness
____
May require a waiting period for pre-existing conditions that is reasonable under correct industry standards
(typically no longer than 6 months)
I certify that the minimum coverage requirements stated above are provided by this policy/plan. I am qualified to
make this determination as an authorized agent/employee of the above insurance provider.
_________________________________
__________________________________________________
Print Name
Contact Information (email and/or phone number)
_________________________________
__________________________________ ______________
Signature
Title
Date
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