Health Insurance Waiver Appeal Form For International Students - Clark University printable pdf download

Clark University Health Insurance Waiver Appeal Form For International Students

(Non-International Students Can

Waive

Online)

All international students who are enrolled in classes at Clark for a semester or more are required to be

enrolled in Clark’s Student Health Insurance Plan (SHIP). In rare cases, participation in the plan will be waived if

the student is carrying acceptable alternate insurance with benefits comparable to the Clark plan (see below).

Coverage by insurance carriers outside of the United States or coverage by foreign National Health Service

programs is not acceptable. Please be aware that international student health insurance plans made available by

firms such as Compass Benefits Group or PSI do not provide adequate benefits and cannot be used to waive the

Student Health Insurance Program requirement.

Waivers will only be granted for international students under the following circumstances:

The student has embassy-sponsored health insurance with benefits comparable to the Clark SHIP.

The student has comparable health insurance through their spouse’s US-based health insurance

plan.

The student has comparable health insurance provided through a US-based employer.

The student will be out of the country for the entire academic year (must show proof of insurance

that will cover the student in their location).

Students meeting the above requirements may submit a written appeal for waiver consideration. In order

to do so, please complete the form below in its entirety and email it, including all supporting documentation, to:

saccounts@clarku.edu.

The Clark University Health Insurance Appeal Committee will then review your documentation and

contact you to inform you of if you are eligible for an insurance waiver. If you do not send all documentation by

email – your appeal request will not be considered.

_____________________________________________________________________________________________

Name: _______________________________

Student ID #:____________________________________

Telephone #:__________________________

Email address: ___________________________________

Were you waived with the plan for a previous academic year? Yes/No

Please check the reason why you are requesting a waiver from Clark’s Student Health Insurance Program:

_____I have embassy-sponsored health insurance with benefits comparable to the Clark SHIP*.

_____I have comparable health insurance through their spouse’s US-based health insurance plan*.

_____ I have comparable health insurance provided through a US-based employer*.

* The above require the following additional documentation:

 Copy of your health insurance plan and full description of benefits and coverage

 Copy of the front and back of your current health insurance card showing your name

_____I will be living in the following country for the entire academic year - __________________________

(Provide a copy of the front and back of your current health insurance card showing your name and also

provide documentation from a Clark Academic Department certifying the period you will be out of the

country)

Please note that all documents are to be submitted in English – including the copy of the insurance card.

Health Insurance Waiver Appeal Form For International Students - Clark University