Insurance Waiver Form | International Student Services

Name*
Given Family Name
Student ID Number*
Student Email*
Phone Number*
Semester applying for:*
Reason for waiver request (select one):*
- I am not an F1 student
- My parent or spouse is living/working in the USA and has medical insurance coverage for me.
- I am a sponsored student and have medical insurance coverage from my sponsoring agency or home government.
- I have Athletic insurance through SAU
Visa Type*
Name of Insurance Carrier*
Policy ID/Number*
Address of Carrier*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Coverage*
MM slash DD slash YYYY
End Date of Coverage*
MM slash DD slash YYYY
Maximum Annual Coverage*
Hidden
Does the policy cover repatriation?
Repatriation is the return of someone's remains to their own country.
- Yes
- No
Amount of Coverage for Repatriation
If your policy doesn't cover repatriation then it can't be used as an alternate policy.
Hidden
Does your policy provide for medical evacuation?
- Yes
- No
Amount of coverage for medical evacuation
If your policy doesn't cover medical evacuation then it can't be used as an alternate policy.
Is your policy in English?*
Name of the policy owner (Primary Insured Person)*
Given Family Name
Upload a copy of your policy*
The policy document explains what your policy covers. This is not your insurance card. Failure to upload the proper documents could result in your request being denied.
Max. file size: 3 MB.
I understand that:
• A denied waiver request OR failure to provide complete and accurate information will result in my automatic enrollment in the Southern Arkansas University international insurance policy.
• If my insurance coverage ends for any reason, it is my responsibility to notify International Student Services.
• Any medical expenses I incur in excess of my insurance coverage are my responsibility and Southern Arkansas University assumes no liability.

I understand that:

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