What is your first name? *

What is your last name? (family name/ surname) *

What is your GVSU G-number? *

What is your GVSU Email address? *
Please enter a GVSU student email address ending in @mail.gvsu.edu.

What is your immigration status? *
- Select Option F1 (Degree seeking student with an I20)) J1 (Exchange student w/ a DS 2019)

Do you have health insurance? *
- Select Option Yes No

What is the name of your insurance company? *

What is your insurance policy id number? *

What is the phone number of your insurance company? *