International Student Services
1519 Clearlake Road, Building 11, Second Floor, Cocoa, FL 32922
Phone: 321.433.7341 | Email: iss@easternflorida.edu
Revised 11/2017 Page 2 of 2
Health Insurance Waiver
Request Form
This form is to be completed and certified (signed below) by the Insurance Company Representative Only and to be accompanied by
page 1 (student signature page).
INSURANCE COMPANY INFORMATION
Insurance Company:
Insured’s Name: Policy #:
Coverage start date: Coverage expiration date:
Eastern Florida State College requires all students holding F-1 student visas be covered by insurance that meets or exceeds the Florida Board of
Governors requirements.
Please verify and check () each requirement that applies to the insurance of the student listed above.
□ 1. Coverage Period: Policies must provide, at a minimum, continuous coverage for the entire period the insured is enrolled as an eligible
student, including annual breaks during that period (ex: Winter Break and Summer Break). Payment of benefits must be renewable.
□ 2. Basic Benefits: Room, board, hospital services, physician fees, surgeon fees, ambulance, outpatient services, and outpatient customary fees
must be paid at 80% or more of usual, customary, reasonable charge per accident or illness, after deductible is met, for in-network, and 60% or
more of usual, customary, and reasonable charge for out-of-network providers per accident or illness.
□ 3. Inpatient Mental Health Care: Must be paid at 80% in-network or 60% out-of-network of the usual and customary fees with a minimum 30-
day cap per benefit period.
□ 4. Outpatient Mental Health Care: Must be paid at 80% in-network or 60% out-of-network of the usual and customary fees with a minimum of
30 (preferably 40) sessions per year.
□ 5. Maternity Benefits: Must be treated as any other temporary medical condition and paid at no less than 80% of usual and customary fees in-
network or 60% out-of-network
□ 6. Repatriation: $25,000 (coverage to return the student’s remains to his/her native country).
□ 7. Medical Evacuation: $50,000 (to permit the patient to be transported to his/her home country and to be accompanied by a provider or
escort, if directed by the physician in charge).
□ 8. Deductible: Maximum of $100 per occurrence for treatment or services rendered at an off-campus ambulatory care or hospital emergency
department facility.
□ 9. Minimum coverage: $100,000 for covered injuries/illnesses per accident or illness per policy year.
□ 10. Insurance Carrier must, at a minimum, meet the rating requirements specified in Part 62.14(d) of Title 22 of the Code of Federal
Regulations.
□ 11. Policy must not unreasonably exclude coverage for perils inherent to the student’s program of study.
□ 12. Claims must be paid in U.S. dollars payable on a U.S. financial institution.
□ 13. Policy provisions must be available from the insurer in English.
I herby certify that all information on this form is complete and accurate and that the health insurance for the student listed above meets all
requirements set foth in items 1-16 above.
Company Representative Title:
Telephone Email
Signature: Date:
