Fillable Printable Insurance Waiver Form - University of Florida

Insurance Waiver Form - University of Florida

International Student Services

1764 StadiumRoad, Suite 170 HUB. PO Box 113225

Gainesville, FL 32611-3225

Phone: 352-273-1540

Fax: 352-392-5575

The Foundation for The Gator Nation

Rev. Oct-13

An Equal Opportunity Institution

Health Insurance Waiver Form

Submit form via email to: insurance@ufic.ufl.edu

It is a Florida State University System’sBoard of Governors (BOG)requirement that all international

students have health coverage at all times while in the United States. If you are going to be in the United

States for any part of a term, you must be covered by health insurance for thatentire term. This is also

for your benefit, as the cost of minor health problems can be far greater than the cost of health

insurance. Please read, complete and email this form to the above email address.

Last Name First NameUFID Telephone Number

E-Mail College Major Degree Level

SELECT ONLY ONE OF THESE OPTIONS TO REQUEST A WAIVER FOR THE SUMMER TERM

Option 1: If you expect to graduate in the Spring term: your Academic Department official and you

must complete the first section of this form. In this case, your I-20 will be shortened to the expected

graduation date.

For the ACADEMIC ADVISOR, GRADUATE CHAIR, DEAN, etc. to complete:

I confirm thatthe above mentioned student is expected to complete all degree requirements and

GRADUATE in the SPRING __________semester.

________________________________________________________________________________________________

Academic Department Official’s Signature Date

________________________________________________________________________________________________

Academic Department Official’s NameTelephone Number

For the student:

I understandmy I-20 will be shortened to the expected graduation date. If I do not graduate, it will

be my responsibility to request an I-20 extension prior to the expiration date. I will be required to

provide proof of funds and of insurance at the time I request the I-20 extension.

_________________________________________________________________________________________

Student’s SignatureDate

Option 2: If you do not expect to graduate in the Spring term, but will not be in the US during the

Summer term: you, as the student, must complete this section of the form. You must also provide a

copy of your flight itinerary showing that you will not be in the U.S. during the summer period. Please

refer to ufic.ufl.edu/ISS/insurance.html for the summer dates.

By signing this form, I confirm that I will NOT be in the United States during the ENTIRE SUMMER

semester. I am providing a copy of my flight itinerary with this form.

_________________________________________________________________________________________

Student’s SignatureDate