{"id":2699,"date":"2017-08-30T14:22:06","date_gmt":"2017-08-30T19:22:06","guid":{"rendered":"https:\/\/web.saumag.edu\/international\/?page_id=2699"},"modified":"2018-03-31T13:31:40","modified_gmt":"2018-03-31T18:31:40","slug":"insurance-waiver-form","status":"publish","type":"page","link":"https:\/\/web.saumag.edu\/international\/forms\/insurance-waiver-form\/","title":{"rendered":"Insurance Waiver Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_42' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_42'  action='\/international\/wp-json\/wp\/v2\/pages\/2699' data-formid='42' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_42' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_42_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 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id=\"field_42_38\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_38'>Semester applying for:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_42_38' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Fall' >Fall<\/option><option value='Summer I &amp; II' >Summer I &amp; II<\/option><option value='Summer II' >Summer II<\/option><option value='Spring' >Spring<\/option><\/select><\/div><\/li><li id=\"field_42_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Reason for waiver request (select one):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_42_11'>\n\t\t\t<li class='gchoice gchoice_42_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='I am not an F1 student'  id='choice_42_11_0'    \/>\n\t\t\t\t<label for='choice_42_11_0' id='label_42_11_0' class='gform-field-label gform-field-label--type-inline'>I am not an F1 student<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_42_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='My parent or spouse is living\/working in the USA and has medical insurance coverage for me.'  id='choice_42_11_1'    \/>\n\t\t\t\t<label for='choice_42_11_1' id='label_42_11_1' class='gform-field-label gform-field-label--type-inline'>My parent or spouse is living\/working in the USA and has medical insurance coverage for me.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_42_11_2'>\n\t\t\t\t<input name='input_11' type='radio' value='I am a sponsored student and have medical insurance coverage from my sponsoring agency or home government.'  id='choice_42_11_2'    \/>\n\t\t\t\t<label for='choice_42_11_2' id='label_42_11_2' class='gform-field-label gform-field-label--type-inline'>I am a sponsored student and have medical insurance coverage from my sponsoring agency or home government.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_42_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_7'>Visa Type<span class=\"gfield_required\"><span 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gfield_label_before_complex' >Address of Carrier<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_42_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_42_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_42_15_1' value=''    aria-required='true'    \/>\n                                        <label for='input_42_15_1' id='input_42_15_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_42_15_2_container' >\n                                        <input type='text' name='input_15.2' id='input_42_15_2' value=''     aria-required='false'   \/>\n                                        <label for='input_42_15_2' id='input_42_15_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_42_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_42_15_3' value=''    aria-required='true'    \/>\n                                    <label for='input_42_15_3' id='input_42_15_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_42_15_4_container' >\n                                        <input type='text' name='input_15.4' id='input_42_15_4' value=''      aria-required='true'    \/>\n                                        <label for='input_42_15_4' id='input_42_15_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_42_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_42_15_5' value=''    aria-required='true'    \/>\n                                    <label for='input_42_15_5' id='input_42_15_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_42_15_6_container' >\n                                        <select name='input_15.6' id='input_42_15_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_42_15_6' id='input_42_15_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_42_16\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_16'>Start Date of Coverage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_16' id='input_42_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_42_16_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_42_16_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_42_16' class='gform_hidden' value='https:\/\/web.saumag.edu\/international\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_42_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_17'>End Date of Coverage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_42_17' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_42_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_42_17_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_42_17' class='gform_hidden' value='https:\/\/web.saumag.edu\/international\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_42_18\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_18'>Maximum Annual Coverage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_18' id='input_42_18' type='text' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_42_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' >Does the policy cover repatriation?<\/label><div class='gfield_description' id='gfield_description_42_33'>Repatriation is the return of someone's remains to their own country.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_42_33'>\n\t\t\t<li class='gchoice gchoice_42_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_42_33_0'    \/>\n\t\t\t\t<label for='choice_42_33_0' id='label_42_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_42_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_42_33_1'    \/>\n\t\t\t\t<label for='choice_42_33_1' id='label_42_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_42_22\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_22'>Amount of Coverage for Repatriation<\/label><div class='ginput_container ginput_container_number'><input name='input_22' id='input_42_22' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_42_23\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If your policy doesn't cover repatriation then it can't be used as an alternate policy.<\/li><li id=\"field_42_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' >Does your policy provide for medical evacuation?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_42_34'>\n\t\t\t<li class='gchoice gchoice_42_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_42_34_0'    \/>\n\t\t\t\t<label for='choice_42_34_0' id='label_42_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_42_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_42_34_1'    \/>\n\t\t\t\t<label for='choice_42_34_1' id='label_42_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_42_25\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_25'>Amount of coverage for medical evacuation<\/label><div class='ginput_container ginput_container_number'><input name='input_25' id='input_42_25' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_42_26\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If your policy doesn't cover medical evacuation then it can't be used as an alternate policy.<\/li><li id=\"field_42_28\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_28'>Is your policy in English?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_42_28' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_42_30\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name of the policy owner (Primary Insured Person)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_42_30'>\n                            \n                            <span id='input_42_30_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_30.3' id='input_42_30_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_42_30_3' class='gform-field-label gform-field-label--type-sub '>Given<\/label>\n                                                <\/span>\n                            \n                            <span id='input_42_30_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_30.6' id='input_42_30_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_42_30_6' class='gform-field-label gform-field-label--type-sub '>Family Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_42_32\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_42_32'>Upload a copy of your policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_42_32'>The policy document explains what your policy covers.  This is not your insurance card.\n\nFailure to upload the proper documents could result in your request being denied.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='3145728' \/><input name='input_32' id='input_42_32' type='file' class='medium' aria-describedby=\"gfield_upload_rules_42_32 gfield_description_42_32\" onchange='javascript:gformValidateFileSize( this, 3145728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_42_32'>Max. file size: 3 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_42_32'><\/div> <\/div><\/li><li id=\"field_42_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">I understand that:<\/h2><\/li><li id=\"field_42_31\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\u2022 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. \n<\/li><li id=\"field_42_36\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\u2022 If my insurance coverage ends for any reason, it is my responsibility to notify International Student Services.<\/li><li id=\"field_42_37\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  > \u2022 Any medical expenses I incur in excess of my insurance coverage are my responsibility and Southern Arkansas University assumes no liability. <\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_42' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_42' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_42' id='gform_theme_42' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_42' id='gform_style_settings_42' value='[]' \/>\n            <input 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