Insured’s Name
International Student Health Insurance Compliance Form (page 2 of 2)
The Insurance Policy must include the following mandated benefits:
Coverage Period: Policies must provide continuous coverage for the entire period the insured is enrolled as an
eligible student, including annual breaks during that period. Payment of benefits must be renewable.
* COVERAGE PERIODS/DATES DIFFER FROM THE ACADEMIC CALENDAR DATES. This ensures that there is no
lapse in coverage
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/illness, after deductible is met for in-network, and 70% or more of usual, customary, or reasonable
charge for out-of-network providers per accident/illness.
Minimum coverage: $200,000 for covered injuries/illnesses per policy year.
Inpatient mental health care must be paid at 80% in-network or 60% out-of-network of the usual and
customary fees within a minimum of 30-day cap per benefit period.
Outpatient mental health care must be paid at 80% in-network or 60% out-of-network of the usual and
customary fees for a minimum of 30 (preferably 40) sessions per year.
Maternity benefits must be treated as any other temporary medical condition and paid at no less than 80% in-
network or 60% out-of-network of the usual and customary fees.
Inpatient/Outpatient prescription medication offers coverage of $1,000 or more per policy year.
Exclusion of pre-existing conditions: First six months of policy period, at most.
Deductible: maximum of $50 per occurrence if treatment or services are rendered at the Student Health
Center, maximum of $100 per occurrence if treatment or service is rendered at an off -campus ambulatory
care or hospital emergency department facility. Policy must not unreasonably exclude coverage for perils
inherent to the student’s program of study.
Repatriation: $25,000 (coverage to return the student’s remains to his/her native country)
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).
Policy provisions must be available from the insurer in English.
Claims must be paid in U.S. dollars payable on a U.S. financial institution.
Insurance Carrier must, at a minimum, meet the rating requirements specified in Part 62.14(c)(1) of the Title
22 of the Code of Federal Regulations, regulating U.S. Department of State Exchange Visitor Program (EVP).
INSURANCE COMPANY REPRESENTATIVE: By signature, I attest this policy covers the above basic benefits. I
certify that the coverage is now in force and if the policy is terminated, I will notify FGCU ISO immediately. I
understand that FGCU is relying on this information to permit the student to register or continue enrollment.
Print Name: Title:
Signature: Date:
STAMP (Required)
Julie Leyden at jleyden@fgcu.edu
Phone: (239) 590-7925
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