PLEASE NOTE: Please state YES (meets minimum requirements) or NO (does not meet) for each of the coverage
requirement and indicate which page number of the attached Schedule of Benefits the benefit is indicated:
1. YES or NO Coverage is pre-paid in full and continuous for a minimum of twelve months from: ___ / ___ / ____ to:
___ /___ /___ or nine months from: ___ / ___/ ___ to: ___ / ___ / ___
2. YES or NO Coverage is not restricted to a specific health care provider. Use of the policy is not restricted to a particular
geographical area.
3. YES or NO The policy provides for coverage of Room & board, hospital services, physician & surgeon fees and
outpatient services paid at 80% or more of PPO Allowance per injury or sickness with no maximum benefit
limit and 60% or more of Usual & Customary charges for out-of-network providers per injury or sickness.
PAGE NUMBER: _______
4. YES or NO Plan does not exclude coverage for pre-existing conditions. PAGE NUMBER: _________
5. YES or NO Deductible is not greater than $250 total per policy year. PAGE NUMBER: _______
6. YES or NO Inpatient & Outpatient mental health care paid at a minimum of 80% in-network or 60% out-of-network of
the usual and customary fees. PAGE NUMBER: ______
7. YES or NO Policy provides coverage for routine preventative services per Federal Law / ACA guidelines.
PAGE NUMBER:
__________
8. YES or NO Maternity benefits treated as any other temporary medical condition. PAGE NUMBER: _______
9. YES or NO Inpatient/Outpatient Prescription Medication: Plan provides copays at local pharmacies with no maximum
policy limit. PAGE NUMBER: ________
10. YES or NO Plan has a preferred provider out of pocket maximum expenses of no more than $7,500 per policy year with
no internal benefit period limitations. PAGE NUMBER: ________
11. YES or NO The policy provides unlimited maximum benefit for covered injuries and sickness per policy year.
PAGE NUMBER: _______
12. YES or NO The policy has claim agents located in the United States, summary of benefits are available in English and
claims are paid in US dollars. PAGE NUMBER: ______________
13. YES or NO The policy provides a minimum of $25,000 for repatriation of remains to the home country and provides a
minimum of $50,000 for medical evacuation, including expenses associated with an attendant, when
medically necessary. PAGE NUMBER:
_________
14. YES or NO Insurance Carrier must have a rating of either “A -” or above by A.M. Best or “A -” or above by Standard
& Poor’s Claims-paying Ability. PAGE NUMBER: ___________
I have verified the information on this form and completed each item above. I certify that the coverage indicated is now in force. If the
above noted policy is terminated, I will notify Palm Beach State College, Office of International Admissions and Recruitment.
N
ame: ______________________________________________ Title: _____________________ Telephone: (____) _____ __
__
Signature: ___________________________________________ Date: ____ / ____ / ____
Please return completed form along with a copy of the policy Schedule of Benefits to:
Office of International Admissions and Recruitment
Palm Beach State College
Fax: (561) 868-3623 Email: international@palmbeachstate.edu
FOR PBSC OFFICE USE ONLY
A
pproved until: _______________________ Denied: ________________________
Authorized Signature: ______________________________ Date: _____ / _____ / ______
