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International Student

Health Insurance Form


*  Denotes A Required Field

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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: $100,000 or more in medical benefits, $25,000 for repatriation of mortal remains, $50,000 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: Aug/15/2015 - Dec/31/2015 $459.75, Jan/1/2016 - May/14/2016 $446.52, and May/15/2016 - Aug/14/2016 $304.29