MIDWESTERN STATE UNIVERSITY

WICHITA FALLS, TEXAS

STUDENT HEALTH INSURANCE PLAN WAIVER REQUEST (2007-2008)

All F-1 International Students are required to carry a United States health insurance policy while attending Midwestern State University. All international students required to carry health insurance will be billed for the Midwestern State University approved health plan. Waivers to MSU’s health insurance policy can be applied for by completing the following form, providing required documentation, and specifically petitioning the Health Insurance Committee for a waiver. Billing will be carried out as follows: students who enter the university for the Fall semester will be billed $245.00 for that semester; students who enter the university for the Spring semester will be billed $374.00 for the remainder of the academic/insurance year; students who enter the university during either the Summer I or Summer II term will be billed $175.00 for the remainder of the academic/insurance year.

To DECLINE coverage under the Student Health Insurance Plan and remove the insurance charge from your account, you must have an alternate insurance plan, from a U.S. provider, that has a minimum of $50,000 major medical and repatriation/medical evacuation benefits. You must also:

1. Make a copy of your insurance card and attach it to this form.

2. Make a copy of the insurance policy and attach it to this form.

3. Provide proof of payment of alternate insurance plan.

4. Complete and Return this form to Kerrie Cale, International Services Office

5. Return this form and all documentation no later than September 8 (Fall semester ); January 27 (Spring semester)

I decline enrollment in the Student Health Insurance Plan. I declare that I have comparable medical insurance coverage, from a U.S. health insurance company, of no less than the amount of coverage provided by Midwestern State University Health Insurance Plan.

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Print Student Name (Last, First) Student CWID Number Date of Birth

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Name of Insured (Print) Relationship to Student

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Name of Insurance Company Policy Number

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Address of Insurance Company

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Policy Expiration Date Phone Number of Insurance Company

I acknowledge by my signature below that health insurance is required to attend Midwestern State University. Should the insurance coverage noted above be terminated while I am enrolled at MSU, I will notify the International Services Office and make arrangements to join the Student Health Insurance Plan. I further acknowledge that a request to waive student health insurance must be submitted every academic year that I attend MSU. I understand that all decisions rendered by the Midwestern State University Health Insurance Committee are final.

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Student Signature Date ISO Personnel Date

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Student Address Phone number

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Student Address Student Email address