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1 Personal Information
For questions about the insurance plan or waiver process, please contact ISO at (800) 244-1180 or waivers@isoa.org. Office hours are Monday to Friday, 9am to 6pm EST.
Student Personal Information
First name
Last name
E-mail address
U.S. Contact Information

U.S. Address
Zip code
City
State
Address
Address (optional)
Phone number (mobile)
Phone number (home)
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2 Alternate Insurance
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Please note: The university and its agents have the right to audit and confirm your policy and coverage information.
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Full name of insurance company
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Insurance company address
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Insurance company phone number
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Your policy effective date
{"ID":618,"FormID":23,"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
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Your policy number
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Does this insurance company have a U.S. based office for submitting claims?
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Relationship to policyholder
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First name of policyholder (If "self" your name)
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Last name of policyholder (If "self" your name)
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3 Insurance Benefits
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Does your insurance provide the following benefits:
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Insurance is valid for the entire 2022 - 2023 academic year from 8/9/2022 to 8/7/2023
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Provides medical benefits of at least $200,000 per policy year
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Pre-existing conditions waiting period no more than 6 months
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Coverage is available in IL and MO for doctors, hospitals, labs, pharmacies and mental health providers
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Offers athletics/sports injury coverage of at least $5,000
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Offers repatriation benefits of at least $25,000
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Offers medical evacuation benefits of at least $50,000
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Reason for waiving insurance
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This waiver form is completed by
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{"ID":635,"FormID":23,"ElementOrder":50,"ElementType":5,"Prompt":"I know the University 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 and proof of coverage for dependents, if applicable. ","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":"Checked","CssClass":null,"Type":{"ID":5,"Name":"CheckBox"}}
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If you have any questions, please contact ISO at (800) 244-1180 or waivers@isoa.org
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