International Student Health Insurance Plan Application Form - Rochester Institute Of Technology
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ROCHESTER INSTITUTE OF TECHNOLOGY
INTERNATIONAL STUDENT HEALTH INSURANCE PLAN APPLICATION FORM
All matriculated, RIT international students on A, B, E, F, G, I, J, K, O, Q, R or V visas are automatically enrolled in RIT’s Student Health
Insurance Plan and billed a semi-annual premium on their student account based on active registration status. All other international students
must apply for the insurance on a voluntary basis by completing this form and submitting the appropriate premium payment. This form may
also be used by international students to add dependent coverage under this same RIT medical plan.
Please note:
Eligibility for spouse/dependent coverage is contingent on the international student’s participation in the RIT medical plan.
Continuing students will need to re-enroll to extend spouse/dependent coverage through the second semi-annual period.
Voluntary enrollment for spouse/dependent coverage ends 30 days after the beginning of the semester in which the
international student starts his/her insurance coverage.
Insurance coverage for spouse/dependents will begin on the first date of the semester in which they are enrolled or the date
insurance premium is received by University Health Plans, whichever is later.
Process for applying for Coverage:
1.
Complete enrollment form information below. Check the box with the desired coverage(s) and extend the cost to the column at right.
2.
Make check out for the amount due made payable to University Health Plans. Partial payments will not be accepted. Credit card
payments are not available.
3.
Mail enrollment form and check to: University Health Plans, One Batterymarch Park, Quincy, MA 02169
INTERNATIONAL STUDENT’S NAME ________________________________ DOB ______________ Univ ID #__________________
Gender:
M / F
LOCAL ADDRESS_______________________________________ ___ City______________________ ____ State
______________ ____ Zip __________
NAME OF SPOUSE _____________________________________________________
Date of Birth (DOB)
___________________
Gender:
M / F
NAME(S) OF DEPENDENT CHILDREN
____________________________________
Date of Birth (DOB)
__________________
Gender:
M / F
____________________________________
Date of Birth (DOB)
__________________
Gender:
M / F
____________________________________
Date of Birth (DOB)
__________________
Gender:
M / F
____________________________________
Date of Birth (DOB)
__________________
Gender:
M / F
PAYMENT OPTIONS
Fall Semester Coverage 8/15/15– 1/14/16
(Due at time of enrollment - deadline is 9/30/15)
PREMIUM
Student
$762
_____________
Spouse (Additional)
$762
_____________
Child (Additional)
$762
_____________
2 or more Children (Additional)
_____________
$1,524
_____________
PREMIUM TOTAL:
Spring Semester Coverage 1/15/16 – 8/14/16
(Due at time of enrollment - deadline is 2/25/16)
PREMIUM
Student
$1,060
_____________
Spouse (Additional)
$1,060
_____________
Child
$1,060
_____________
2 or more Children (Additional)
$2,120
_____________
_____________
PREMIUM TOTAL:
PLEASE NOTE THAT IT IS THE STUDENT’S RESPONSIBILITY TO RE-ENROLL DEPENDENTS FOR
THE SPRING SEMESTER PLAN PRIOR TO THE END OF THE FALL SEMESTER PLAN TO ENSURE
CONTINUOUS COVERAGE.
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