International Student

Health Insurance Form

* Denotes A Required Field

Your Information

First Name:*

Middle Name:

Last Name:*

G Number:*

Date Of Birth:*
Month: Day: Year:

Gender:*

Address:*

Address 2:

City:*

State:*

Zip Code:*

Country Of Citizenship:*

Email Address:*

Cell Phone: (xxx-xxx-xxxx)

Insurance Preference
Section A

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.

Section B

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 2016-17 academic year:
Aug 15, 2016 - Dec 31, 2016 = $488.34
Jan 1, 2017 - May 14, 2017 = $470.75
May 15, 2017 - Aug 14, 2017 = $323.21

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

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