Insurance coverage must be effective the first day the semester and continue throughout your
enrollment at FGCU, including school breaks and summer terms.
Determine which insurance to use:
If you purchase one of the plans listed below, click here this link to:
upload your Insurance Confirmation
Letter with documentation showing the policy effective date and termination date.
Pre-Approved Insurance Plans
Gallagher Student Health & Special Risk Insurance
This is the recommended plan for students attending any school in the
Florida University System
https://iss.gallagherstudent.com/
(ISP)-International Student Protection
Plans showing Florida Trail Blazer Basic or Florida Trail Blazer Elite
www.intlstudentprotection.com
(ifs) Insurance for Students
www.insuranceforstudents.com
ISO International Student Insurance
https://www.isoa.org/
FGCU does not endorse any of the companies listed above. Each student must choose their own insurance; we cannot choose it for you. The
companies listed meet the FGCU requirements but are not your only option. Please do NOT send any insurance plans for our office to review.
If you do not purchase insurance through one of the pre-approved plans listed above, you must
complete the International Student Health Insurance Compliance Form on the next two pages.
Complete Part 1, sign and submit both pages of the form to your insurance company. They will determine
if the plan meets FGCU/State requirements. Part 2 should be completed by your insurance. The insurance
carrier must check and sign Page 2 of the International Student Health Insurance Compliance Form and
return both pages to our office via Fax (Fax: 239-590-7977) or email (jleyden@fgcu.edu)
Although you may have some type of medical insurance, the University can only accept your insurance if
it meets all of the listed requirements. (Please read the instructions on the FGCU International Student
Health Insurance Compliance Form which also outlines the minimum requirements established by the
State of Florida.)
If your insurance company does not meet all of the requirements listed on page 2 of the International
Student Health Insurance Compliance Form, you may need to purchase a supplemental policy.
Failure to comply with these requirements may force Florida Gulf Coast University to terminate your immigration status.
Health Insurance Requirements
International Students
International students must comply with the Florida Board of Governors rule requiring all international students to
have medical insurance in order to register or enroll in classes. Rule 6.009(2) provides that, “no international student
in F or J non-immigrant status shall be permitted to register, or to continue enrollment, at a university without
demonstrating that the student has adequate medical insurance coverage for illness or accidental injury.” Specifically,
this rule requires that insurance policies must provide, at a minimum, continuous coverage for the entire period that
the insured is enrolled as an eligible student, including breaks between or during terms (for students enrolled in more
than one term/semester, this means a full year).
International Student Health Insurance Compliance Form
(Page 1 of 2)
To comply with Florida State Board of Governors Regulation BOG 6.09, International Students must have health
insurance. Students in F and J status must maintain health insurance coverage from the first day of class until the
last day before the next semester, thus insuring that there is no lapse in coverage.
I authorize my insurance company to release the information on this form to Florida Gulf Coast University.
By signing below, I agree to the following requirements established by FGCU and I agree to abide by them.
1. Alternate insurance policies are approved for limited periods not exceeding one academic year and the
requirements for alternate policy coverage are subject to change.
2. I must have my policy information re-certified EACH semester.
3. Failure to have continuous coverage which meets the minimum requirements outlined on the attached
checklist will result in a hold being placed on my student Gulfline account.
4. If the alternate insurance coverage is not approved, this does not mean FGCU or any of its employees
recommend that I cancel any existing, pending, or proposed insurance coverage.
5. The policy presented must meet the minimum requirements established by FGCU and the State of Florida
with respect to specific medical insurance coverage criteria
6. I understand that the insurance I have chosen may not be comparable to the recommended plan provided
through Gallagher Student Health & Special Risk Insurance
. I also understand that by using an alternate
plan, there is a potential for higher deductibles, co-pays and out of pocket expenses.
Student Name (Please Print):
Student FGCU ID# (UIN)
Signature of Student: Date:
*************************** STOP! Below this line to be completed by insurance provider only! ***********************************
Insured’s Name
Coverage Start Date Coverage End Date
(mm/dd/yyyy) (mm/dd/yyyy)
Insurance Company Policy #
Agent name:
Agent email Address Agent Phone Number
U.S Claims Company Address: (If Available)
U.S Claims Company Phone: (If Available)
Return both pages of this form to FGCU via fax (Fax: 239-590-7977) or email to: jleyden@fgcu.edu
PART 2: TO BE COMPLETED BY INSURANCE COMPANY REPRESENTATIVE
PART 1: TO BE COMPLETED BY STUDENT
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signature
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Insureds 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
click to sign
signature
click to edit