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: $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 2013-2014 academic year 8/15/2013 - 12/31/2013 - $433.28, 1/1/2013 - 5/14/2013 - $421.15 and 5/15/2013 - 8/14/2013 - $280.82.


I understand that international students are required to have health insurance for the duration of the academic program.