Insurance Waiver FormName* Given Family Name Student ID Number*Student Email*Phone Number*Reason for waiver request (select one):*I am not an F1 studentMy 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 SAUVisa Type*F2H1bH4Permanent Resident/otherName of Insurance Carrier*Policy ID/Number*Address of Carrier* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Start Date of Coverage* End Date of Coverage* Maximum Annual Coverage*Does the policy cover repatriation?Repatriation is the return of someone's remains to their own country.YesNoAmount of Coverage for RepatriationIf your policy doesn't cover repatriation then it can't be used as an alternate policy.Does your policy provide for medical evacuation?YesNoAmount of coverage for medical evacuationIf your policy doesn't cover medical evacuation then it can't be used as an alternate policy.Is your policy in English?*YesNoName 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.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.
