Fillable International Health Insurance Waiver Request Form printable pdf download

International Health Insurance Waiver Request Form

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International Health Insurance

Waiver Request Form

(Students on OPT should use the OPT Insurance Waiver Form)

The purpose of this form is to request cancellation of your International Health Insurance because

you have other insurance that meets UM insurance requirements.

 Complete this form & submit with below documents in person to the International Center

Insurance Office, or scan & email to ihi@umich.edu.



Proof of Insurance

: A copy of your insurance card/certificate or insurance contract. If your insurance

plan covers your dependents, please also attach proof that they are covered by the plan.

 A copy of your insurance plan booklet in English. This information should include the specific

details of your insurance coverage, including any restrictions, limits, or exclusions in your

coverage while you are in the U.S..

Requests are usually evaluated within two weeks. You will receive email notification at your UM

email once your request is approved or denied.

------------------------------------------------------------------------------------------------------------------------------------------------- ----

LAST NAME

FIRST NAME

UM I.D. #

INSURANCE COMPANY:

POLICY NUMBER:

8/31/2017

WAIVER START

WAIVER END

program end date (if earlier):

DATE:

DATE*:

*Note: all waivers expire on August 31, and must be renewed each September.

CHECK BELOW ONLY IF YOUR INSURANCE PROVIDED BY:



A SPONSOR NAME OF SPONSOR__________________________________________



A FAMILY MEMBER

FAMILY MEMBER NAME

RELATIONSHIP

UM I.D. #

(if UM employee)

SIGNATURE

DATE

----------------------------------------------------------------------------------------------------------------------------- ------------------------------------

 APPROVED

 DENIED

For Office Use Only:

Authorization:______________________________ Date: _____________ Documents:

Attached

Imaged

None

Rev 5/07 DP

Page 1 of 1

08/16

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 Ann Arbor MI  48109-1316