Fillable INTERNATIONAL STUDENT HEALTH INSURANCE COMPLIANCE FORM (Palm Beach State College)

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INTERNATIONAL STUDENT HEALTH INSURANCE COMPLIANCE FORM (Palm Beach State College)

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The INTERNATIONAL STUDENT HEALTH INSURANCE COMPLIANCE FORM (Palm Beach State College) form is 2 pages long and contains:

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OFFICE OF INTERNATIONAL
ADMISSIONS AND RECRUITMENT
INTERNATIONAL STUDENT
HEALTH INSURANCE COMPLIANCE FORM
This form has been designed to assist international students in complying with the College’s rule requiring all international students to
have a health and accident insurance in order to register or enroll in classes. If you wish to purchase an alternate policy, you must
provide proof that your proposed policy provides benefits at least equal to those required by PBSC. The following types of plans are
NOT accepted:
Travel insurance
Short-term in-bound insurance policies
Reimbursement plans
Any plan that does not fully meet each of the 14 benefit requirements of this compliance form
Student must complete Section I below and have their insurance carrier to complete Section II and return it along with a copy
of the policy Schedule of Benefits to the Office of International Admissions.
SECTION I – To be completed by Student
Print Name: _______________________________________________________ PBSC Student ID #: ______-______-_______
I hereby permit my insurance company to release the following information to personnel at Palm Beach State College. Also, I
understand the international insurance requirements established by PBSC and agree to abide by them. I understand that alternate
insurance policies are approved for limited periods not exceeding one year, and that requirements for alternate policy coverage are
subject to change. I further understand that I must have my policy reviewed at the end of the approval period indicated below.
I understand that, if alternate insurance is not approved, this does not mean that PBSC or any of its employees recommend that I
cancel any existing, pending or proposed insurance coverage. A denial implies only that the policy presented does not meet the
minimum criteria established by PBSC with respect to specific medical insurance coverage criteria for registration and/or enrollment.
Signature: ____________________________________________ Date: _____ / _____ / ______
SECTION II – To be completed by the Insurance Company
Student Name: ___________________________________________________________________________________________
Insurance Co. Name: ______________________________________________________________________________________
Policy #: _______________________________________ Dates of Coverage: (Beginning - Ending) ______________________
U. S. Claims Agent Name: __________________________________________________________________________________
U. S. Claims Agent Address: _______________________________________________________________________________
U. S. Claims Agent Phone: (_____) ______ ___________ Fax Number: (______) _____ ______ _______
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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 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 major medical expenses at a minimum of 80% of usual, reasonable,
and customary charges without specific limits on charges such as hospital room and board, hospital
miscellaneous, physician visits, surgery, anesthesia, etc. PAGE NUMBER: _______
4. YES or NO Plan does not exclude pre-existing conditions. PAGE NUMBER: _________
5. YES or NO Deductible is no greater than $100 per accident /illness and per person. PAGE NUMBER: _______
6. YES or NO Inpatient 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 Outpatient mental health care paid at a minimum of 80% in-network or 60% out-of-network of the usual
and customary fees with a 30-day cap per benefit period. 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: includes coverage of $1,000.00 or more per policy year.
PAGE NUMBER: ________
10. YES or NO Plan has a preferred provider out of pocket maximum expenses of no more than $6,350 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. PAGE NUMBER: ______________
13. YES or NO The policy provides a minimum of $25,000 for repatriation of remains to the home country. PAGE NUMBER:
_________
14. YES or NO The policy provides a minimum of $50,000 for medical evacuation to the home country, including
expenses associated with an attendant, when medically necessary. 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.
Name: ______________________________________________ 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
4200 South Congress Avenue, Lake Worth, FL 33461
Tel: (561) 868-3029 Fax: (561) 868-3623 Email: international@palmbeachstate.edu
FOR PBSC OFFICE USE ONLY
Approved until: _______________________ Denied: ________________________
Authorized Signature: ______________________________ Date: _____ / _____ / ______
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INTERNATIONAL STUDENT HEALTH INSURANCE COMPLIANCE FORM (Palm Beach State College)

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Completed 1 February 2021

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