*This form requires signatures. If you are emailing this form, scan the signed document and send it as an attachment.
Minnesota State Colleges and Universities
Student Health Insurance Petition for Refund
_________ - _________ Academic Year
Campus:
Bemidji State University St. Cloud State University
Metropolitan State University Southwest State University
Minnesota State University, Mankato Winona State University
Minnesota State University, Moorhead MN Community/Technical College: Name of Campus: _____________________________
PLEASE PRINT CLEARLY:
Name (Last) _______________________________________ Name (First) _____________________________________
Date of Birth______________________ Student ID# ______________________ Phone #___________________________
Refund Address: (Allow up to 6 weeks to process refunds)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Please read the following and check the appropriate box:
I have left for my home country due to concerns of Covid-19.
I have been approved for OPT and am not required to purchase student health insurance while on OPT
I am no longer enrolled because I transferred to another college/university*
I left the United States and will not return to this college/university within the next year
I am no longer in F or J immigration status and am not required to purchase student health insurance (must show
form I-797 Notice of Approval from USCIS , I-551 Permanent Resident Card, or other document verifying approved change of
status)
I elect to have student health insurance coverage dropped on the effective date: ___________________________________
To the student:
By signing below, I am verifying that the above statement is true. I understand that I am no longer required to maintain
MnSCU student health insurance and that I will be solely responsible for all medical and/or dental bills. Under no
circumstances is the college/university responsible for any of my medical or dental bills incurred during such coverage or after
it is no longer in effect.
Signature of Student _______________________________________________________ Date _______________________
International Student Advisor Approval ________________________________________ Date ______________________
Advisor Name and Title ___________________________________________________________________________________
Comments _____________________________________________________________________________________________
*If you are transferring to another MN State College/University you should maintain student health insurance. You will continue to receive
insurance benefits for existing claims or claims that may occur in the quarters/semesters that you do not attend the college/university. If you do
not continue coverage and a break in coverage occurs, you must wait one year or longer to receive benefits for any pre-existing condition.
**Note: Refunds are calculated from the date the insurance company is notified to drop the coverage using this completed form. Please allow up
to six weeks for the refund to be processed. If you have not received your refund after six weeks you may call United Healthcare Student Resources
at 1-888-251-6243. Please keep a copy of this form for your own record.
STUDENT: YOU ARE RESPONSIBLE FOR FAXING OR E-MAILING THIS FORM
Fax: 469-229-5612 (Attention Premium Refunds)
E-Mail*: SidPremiumAccountingCustomerService@uhcsr.com
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Century College
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