First Name *

Last Name *

Email *

Phone *

G-number *

Study abroad provider *

Name of the insurance provider you will be covered by *

Please upload a copy of the insurance policy *
Please upload a file with the extension .doc, .pdf, .docx, .jpeg, .jpg, or .png with a maximum size of 5 MB (5120 KB)

NOTE: If you answer 'no' to any of the following questions, we strongly recommend you reconsider requesting an exemption. The Chubb plan through GVSU offers coverage at this level or higher.

Does the insurance plan you will be covered through provide the following:

Includes pre-existing conditions? *
- Select Option Yes No

If you have a pre-existing condition, GVSU strongly recommends you not request an exemption of the GVSU mandatory insurance program. The Chubb plan available through GVSU does cover pre-existing conditions.

Accident and sickness coverage of $250,000 or more? *
- Select Option Yes No

Deductible of less than $100? *
- Select Option Yes No

Emergency evacuation of $250,000 or higher? *
- Select Option Yes No

Security evacuation of $50,000 or higher? *
- Select Option Yes No

Repatriation of remains of $100,000 or higher? *
- Select Option Yes No

Emergency family reunion $5000 or higher? *
- Select Option Yes No

Accidental death and dismemberment $10,000 or higher *
- Select Option Yes No

Mental health coverage? *
- Select Option Yes No

If you do not have mental health coverage, GVSU strongly recommends that you not request an exemption of the GVSU mandatory insurance program. The Chubb plan available through GVSU does offer mental and nervous disorders at $10,000 for inpatient or outpatient services.

Are you covered under any other plan that provides coverage for the above listed items? *
- Select Option Yes No

If yes, please upload a copy of the insurance brochure that details the additional policy that you will be covered under. *
Please upload a file with the extension .doc, .pdf, .docx, .jpeg, .jpg, or .png with a maximum size of 5 MB (5120 KB)