ISO

1 Personal Information

For questions about the insurance plan or waiver process, please contact ISO at (800) 244-1180 or customercare@isoa.org. Office hours are Monday to Friday, 9am to 6pm EST.

Student Personal Information

First name

Last name

E-mail address

Gender

Male Female

Date of birth

Student ID or passport number

U.S. Contact Information

U.S. Address

Zip code

City

State

Address

Address (optional)

Phone number (mobile)

Phone number (home)

{"ID":807,"FormID":30,"ElementOrder":1,"ElementType":6,"Prompt":"Alternate Insurance","Options":"","Mandatory":false,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":6,"Name":"SectionHeader"}}

Cancel

2 Alternate Insurance

{"ID":808,"FormID":30,"ElementOrder":15,"ElementType":1,"Prompt":"Please note: The university and its agents have the right to audit and confirm your policy and coverage information.","Options":"","Mandatory":false,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":1,"Name":"DisplayText"}}

Please note: The university and its agents have the right to audit and confirm your policy and coverage information.

{"ID":809,"FormID":30,"ElementOrder":16,"ElementType":2,"Prompt":"Full name of insurance company","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}

Full name of insurance company

{"ID":810,"FormID":30,"ElementOrder":17,"ElementType":2,"Prompt":"Insurance company address","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}

Insurance company address

{"ID":811,"FormID":30,"ElementOrder":18,"ElementType":2,"Prompt":"Insurance company phone number","Options":"","Mandatory":true,"RegExToSubmit":"([0-9]{3})?[-.â—]?([0-9]{3})[-.â—]?([0-9]{4})","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}

Insurance company phone number

{"ID":812,"FormID":30,"ElementOrder":19,"ElementType":7,"Prompt":"Your policy effective date","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":7,"Name":"Date"}}

Your policy effective date

{"ID":813,"FormID":30,"ElementOrder":20,"ElementType":7,"Prompt":"Your policy termination date","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":7,"Name":"Date"}}

Your policy termination date

{"ID":814,"FormID":30,"ElementOrder":21,"ElementType":2,"Prompt":"Your policy number","Options":"","Mandatory":true,"RegExToSubmit":"([a-zA-Z0-9_]","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}

Your policy number

{"ID":815,"FormID":30,"ElementOrder":22,"ElementType":4,"Prompt":"Is the insurance company operating in the US with a US claims address and accessible customer service telephone number?","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Yes","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}

Is the insurance company operating in the US with a US claims address and accessible customer service telephone number?

Yes No

{"ID":816,"FormID":30,"ElementOrder":25,"ElementType":4,"Prompt":"Relationship to policyholder","Options":"Self, Parent, Spouse, Guardian, Employer","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}

Relationship to policyholder

Self Parent Spouse Guardian Employer

{"ID":817,"FormID":30,"ElementOrder":26,"ElementType":2,"Prompt":"First name of policyholder (If \"self\" - please provide your first name)","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}

First name of policyholder (If "self" - please provide your first name)

{"ID":818,"FormID":30,"ElementOrder":27,"ElementType":2,"Prompt":"Last name of policyholder (If \"self\" - please provide your last name)","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}

Last name of policyholder (If "self" - please provide your last name)

{"ID":819,"FormID":30,"ElementOrder":28,"ElementType":6,"Prompt":"Waiver Criteria","Options":"","Mandatory":false,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":6,"Name":"SectionHeader"}}

Cancel

3 Waiver Criteria

{"ID":820,"FormID":30,"ElementOrder":29,"ElementType":1,"Prompt":"Please select the category for a waiver that applies to you below:","Options":"","Mandatory":false,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":1,"Name":"DisplayText"}}

Please select the category for a waiver that applies to you below:

{"ID":821,"FormID":30,"ElementOrder":30,"ElementType":4,"Prompt":"I am an international student athlete covered through the athletic department","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}

I am an international student athlete covered through the athletic department

Yes No

{"ID":822,"FormID":30,"ElementOrder":31,"ElementType":4,"Prompt":"I am covered as a dependent under a US based employer health insurance plan through my parent/spouse","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}

I am covered as a dependent under a US based employer health insurance plan through my parent/spouse

Yes No

{"ID":823,"FormID":30,"ElementOrder":32,"ElementType":4,"Prompt":"I am covered through my home country embassy health insurance (e.g. SACM) ","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}

I am covered through my home country embassy health insurance (e.g. SACM)

Yes No

{"ID":828,"FormID":30,"ElementOrder":46,"ElementType":4,"Prompt":"Repatriation coverage of at least $50,000?","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Yes","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}

Repatriation coverage of at least $50,000?

Yes No

{"ID":829,"FormID":30,"ElementOrder":48,"ElementType":4,"Prompt":"Medical evacuation coverage to home country at least $100,000?","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Yes","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}

Medical evacuation coverage to home country at least $100,000?

Yes No

{"ID":831,"FormID":30,"ElementOrder":52,"ElementType":2,"Prompt":"Reason for waiving insurance","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":2,"Name":"Text"}}

Reason for waiving insurance

{"ID":832,"FormID":30,"ElementOrder":53,"ElementType":2,"Prompt":"Waiver form is completed by (Type name):","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":2,"Name":"Text"}}

Waiver form is completed by (Type name):

{"ID":833,"FormID":30,"ElementOrder":54,"ElementType":5,"Prompt":"By submitting this waiver request, I understand that I am requesting not to be enrolled in the health insurance offered by ISO and Augustana College and the waiver is ONLY VALID for FALL 2025 semester. \nI understand that I am responsible for submitting documentation EACH SEMESTER to prove I have an alternative insurance plan that meets the waiver requirements listed above. Furthermore, I understand the risks involved by declining the ISO insurance plan and opting for my own insurance plan. ","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Checked","CssClass":"","Type":{"ID":5,"Name":"CheckBox"}}

By submitting this waiver request, I understand that I am requesting not to be enrolled in the health insurance offered by ISO and Augustana College and the waiver is ONLY VALID for FALL 2025 semester. I understand that I am responsible for submitting documentation EACH SEMESTER to prove I have an alternative insurance plan that meets the waiver requirements listed above. Furthermore, I understand the risks involved by declining the ISO insurance plan and opting for my own insurance plan.

{"ID":834,"FormID":30,"ElementOrder":55,"ElementType":5,"Prompt":"I know the college and/or its agents has the right to request in writing evidence of health insurance coverage. Evidence of such coverage can be furnished by submitting the front and back of your health insurance ID card, a copy of the insurance policy and a letter from the insurance company confirming coverage is in effect during your period of enrollment.","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Checked","CssClass":"","Type":{"ID":5,"Name":"CheckBox"}}

I know the college and/or its agents has the right to request in writing evidence of health insurance coverage. Evidence of such coverage can be furnished by submitting the front and back of your health insurance ID card, a copy of the insurance policy and a letter from the insurance company confirming coverage is in effect during your period of enrollment.

{"ID":835,"FormID":30,"ElementOrder":56,"ElementType":1,"Prompt":"If you have any questions, please contact ISO at (800) 244-1180 or customercare@isoa.org","Options":null,"Mandatory":false,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":1,"Name":"DisplayText"}}

If you have any questions, please contact ISO at (800) 244-1180 or customercare@isoa.org

Cancel

Finish