Submit waiver request

First Name (Same as passport)

Last Name (Same as passport)

Email Address

Student ID#

Date of Birth

	Yes	No	Waivers only approved if your insurance meets ALL of these requirements.
1.			Does your plan cover $100,000 per accident / illness
2.			Does your plan cover $25,000 repatriation
3.			Does your plan cover $50,000 medical evacuation
4.			Does your plan have a Deductible not to exceed $500 per accident / illness
5.			Does your plan use English, U.S. currency, and have a U.S. billing address and phone number
6.			Does your plan have Inpatient and outpatient medical coverage for hospitalization, emergency room, urgent care, maternity, physical therapy and mental health services
7.			Does your plan have Prescription (medication) coverage
8.			Does your plan have coverage for pre-existing condition, not greater than 6 month waiting period
9.			Does your plan provide coverage from first day of classes to the final day of exams?

Required: Attach Insurance ID or Confirmation Letter

Attach Policy Brochure showing the Benefits

Coverage Start Date (If Employer-based insurance through parent or spouse, select 1st day of classes)

Coverage Start Coverage End Date (If Employer-based insurance through parent or spouse, select end of this school year, June 30)

PSI Health Insurance