Health Insurance Form

It’s Internexus policy that all students have health insurance coverage. Please, fill out the

form below with your personal information. If you have any dependents, fill out a

separate form for each person.

Personal Information:

First Name: ___________________ Last Name: __________________

Gender:  Male  Female

Date of Birth: ______________ (Month/Day/Year)

Country: ______________________

Date you’re going to leave your country: __________________ (Month/Day/Year)

Date you’re going to return to your country: __________________ (Month/Day/Year)

Health Insurance Plan:

 I have my own health insurance:

Company: ___________________________

Policy Number: _______________________

Expiration Date: __________________ (Month/Day/Year)

(Please, attach a copy of your insurance card or confirmation.)

 I will buy insurance from Internexus for ____________ months.

($85 for the first month, $75 for following months)

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Parent category: Legal

Health Insurance Form - Internexus