International Student

Health Insurance Form

*  Denotes A Required Field

Your Information

Insurance Preference

I elect not to purchase the Insurance Plan offered by Grand Valley State University. By checking this box and signing below, I am certifying that I have purchased a policy that meets the minimum standards required by the university: $50,000 or more in medical benefits, $7,500 for repatriation of mortal remains, $10,000 for medical evacuation to my home country, and $500 or smaller deductible amount. I also certify that I will maintain this coverage at all times while I am a student at Grand Valley State University.

I wish to purchase the insurance plan offered by Grand Valley State University. My Insurance Premium will be charged to my Student Account. Cost for the 2014-15 academic year 8/15/14 - 12/31/14 - $508.49, 1/1/15 - 5/14/15 - $490.20, and 5/15/15 - 8/14/15 - $336.55