Fillable Printable Insurance Waiver Template

Insurance Waiver Template

Students who wish to waive UCI health insurance must submit this Waiver with their application. All

students who do not complete this Waiver by the program start date will automatically be enrolled in the

UCI health insurance plan, and will be responsible for paying those fees.

Please write clearly.

Family Name First Name

Telephone Email (required)

Preferred Street Address City

Country Postal Code

Select the program the applicant will attend

o Session I (June 22 - July 29) o 10-week Session (June 22 - August 28) o Session II (August 3 - September 9) o Session I and II (June 22 - September 9)

is waiver is to certify that I, the above named student, am waiving coverage of the health insurance plan oered to me

by the University of California, Irvine, University Extension Program in Summer Session (UCI UNEX), for coverage

during the above-specied program dates. In addition, because I am waiving the UCI UNEX health insurance, I am

guaranteeing that I will instead be covered by an independent health insurance plan which I will arrange myself. is

independent health insurance plan meets the following minimum required coverages.

$500,000 Maximum benefit per Policy Year

$25,000

Minimum coverage for Evacuation Expenses to your home country if necessary

$10,000 Minimum coverage for Repatriation of Remains to your home country in case of death

The deductible does not exceed $75.00 per injury/illness

I understand that during my program of study, adequate health insurance coverage, as dened by the minimum coverages

above, is required by UCI UNEX.

Insurance Company Name

Policy Number

Contact Phone Number

Coverage Dates

SIGNATURE DATE

2015 Deadlines to submit waivers: Session I: May 29 Session I and II: May 29 10-week: May 29 Session II: July 2

2015 UCI Summer Session

Health Insurance Waiver & Guarantee of Independent Coverage

PO Box 6050 • Irvine, CA 92616-6050 • Telephone (949) 824-4270 • Email: internationalsummer.uci.edu