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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":646,"FormID":24,"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 duration of your program?
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Provides medical benefits of at least $100,000 per accident or illness
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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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Offers a deductible that does not exceed $500 per accident or illness
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Are you a student athlete? If yes, you will be required to show proof of coverage for athletic injuries
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Reason for waiving insurance
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This waiver form is completed by
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If you have any questions, please contact ISO at (800) 244-1180 or waivers@isoa.org
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