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 1 of 2
Health Insurance Waiver
Request Form
This form has been designed to assist international students in complying with Eastern Florida State College regulation
requiring all international students to have health insurance when attending the College (to register or enroll in college
classes). If you have already purchased an alternate policy, you must show proof that your policy provides benefits at
least equal to those required by Eastern Florida State College.
Instruction to Student: Please complete page one of this form. Send page two to your insurance company. The
insurance company must verify that the basic benefits listed on page two are included in the health insurance policy. If
any of these benefits listed on page two are not covered through the alternate health insurance policy, you will not be
considered properly insured and will be unable to register for classes or continue enrollment.
STUDENT INFORMATION
Student Name: EFSC ID #:
Email: Phone:
Semester: Year:
STUDENT CERTIFICATON (Required)
I understand that this application must comply with the requirements for alternative health insurance plans to
EFSC’s Prime Plan or I may be subjected to penalties affecting my enrollment at Eastern Florida State College.
I understand that if my insurance coverage (for which my waiver approval is granted) terminates for any reason,
it is my responsibility to notify ISS, and to immediately purchase insurance so that there is no break in coverage.
I understand that upon receiving waiver approval I am solely responsible for all costs relating to the purchase of
insurance and nay medical expenses not covered by the policy I select.
I understand that my health insurance coverage must be in effect on or before the first day of classes attended
and must remain in effect for the duration of my program at EFSC.
I understand that I am responsible for renewing my insurance premiums annually.
I hereby give consent for my insurance agent to notify Eastern Florida State College if the insurance I have
purchased for myself and dependents expires, and/or for EFSC to contact the insurance agent to verify the
status of my insurance if questions arise about my coverage.
Student Signature: Date:
This is your signature page to confirm that you understand all of the above and to allow a representative of the
insurance company providing coverage to complete and return the second page.
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: