Florida International University International Student Health Insurance Compliance Form
Download a blank fillable Florida International University International Student Health Insurance Compliance Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Florida International University International Student Health Insurance Compliance Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2FLORIDA INTERNATIONAL UNIVERSITY
INTERNATIONAL STUDENT HEALTH INSURANCE COMPLIANCE FORM
ACADEMIC YEAR 2016-2017
This form has been designed to assist international students in complying with the FIU rule requiring all international students
to have insurance in order to register for classes. FIU offers a policy that meets the minimum standards of required coverage
as per Florida Board of Governors Rule 7(d) 6.009, F.A.C. If you wish to purchase an alternative policy, you must provide proof
that your proposed policy provides benefits at least equal those required by FIU.
INSTRUCTIONS TO STUDENT: Ask your insurance company to complete this form and email or fax it directly to:
FIU Student Health Services
insure@fiu.edu
OR
Biscayne Bay Campus, North Miami, FL 33181, FAX: (305) 919-5312
OR Modesto A. Maidique Campus, Miami, FL 33199, FAX: (305) 348-3336
The insurance company must verify that the basic benefits listed below are included
in your health insurance policy; if any of these benefits are not covered, you will not
be able to register for classes or continue enrollment at FIU.
Release of Information: I hereby permit my insurance company to release the following information to staff personnel at
Florida International University. Also, I understand the international insurance requirements established by FIU and agree to
abide by them. I understand that alternate insurance policies are approved for limited periods not exceeding one academic
year and the requirements for alternate policy coverage are subject to change. I further understand that I must have my policy
reviewed at the end of the approval period indicated below.
I understand that, if alternate insurance is not approved, this does not mean that FIU or any of its employees recommend that
I cancel any existing, pending or proposed insurance coverage. A denial implies only that the policy presented does not meet
the minimum criteria established by FIU with respect to specific medical insurance coverage criteria for registration and/or
enrollment.
Print Name: ____________________________ Signature: _____________________ Email: ___________________________
Panther ID#: ____________________________ Visa-Type: _____________________ Expected Graduation: ______________
INSTRUCTIONS TO INSURANCE COMPANY: Please complete the form on page 1 and 2. Indicate the insured’s name, the
insurance company name, U.S. claims agent/address/phone, policy number, and dates of commencement and termination of
coverage. For items 1-15 state “YES” for every benefit that meets or exceeded in the insured’s policy. State “NO” for benefits
not covered or that do not meet the stated minimum amount of coverage. Please print your name and title, then sign and
date the form on page 2.
Student Name: _________________________________________________Date of Birth: ___________________________
(Last/family name)
(First/given name)
(MM/DD/YYYY)
Insurance Co. Name: ______________________________________________ Policy #: ______________________________
U.S. Claims Agent Address: _ ___________________________________ _U.S. Claims Agent Phone: _ __________________
Dates of Coverage (MM/DD/YYYY; REQUIRED): ______________ ___/__________________
Start Date
End Date
The following minimum dates of coverage are required in order to register or continue enrollment:
Semester
Dates of Coverage
Fall 2016/Spring 2017/Summer 2017:
August 17, 2016 to August 16, 2017
Fall 2016:
August 17, 2016 to December 31, 2016
Spring 2017/Summer 2017:
January 1, 2017 to August 16, 2017
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal