Fillable Fillable Health InsFORM5 13 (California State University, Fresno)

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Fillable Health InsFORM5 13 (California State University, Fresno)

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California State University, Fresno
Division of Continuing and Global Education
INTERNATIONAL STUDY HEALTH AND ACCIDENT INSURANCE
In conformity with directives of the Office of the Chancellor of the California State
University and Colleges, Foreign Study Procedures, Executive Order No. 165,
November 10, 1972, Section 3.6 A-(2).
(2) Health and accident covering foreign travel.
____________________________________________
Participant’s name (please print)
enrolled in a California State University, Fresno Travel/Study Program, hereby
certifies that he/she has the minimum health and accident insurance coverage
required to participate in this Travel Study Program.
Policy No: _________________________
Carrier: ___________________________
________________________________
Participant’s signature
________________________________
Date
Return form to: Study Abroad and International Exchanges
Family and Food Sciences, Room 119
5300 N. Campus Dr. M/S FF83
Fresno, CA 93740-8019
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Completed 18 July 2020

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