NOTE: Policy is not available to persons whose home address is in:
If you have the free Adobe Acrobat Reader on your computer, you can view/print the brochure and or application here:
Most U.S. health insurance programs provide little or no coverage outside the United States. This special health insurance program was designed for: U.S. citizens; permanent residents of the U.S.; international student in the U.S.; or enrolled as a full-time student in a U.S. institution and are temporarily pursuing educational activities outside of the United States. International students are not eligible for coverage in their home country. The policy provides coverage from your date of departure until your date of return to the USA. It includes several special coverages not typically found in most health insurance programs. These unique coverages are tailored to the special circumstances of your "Study Abroad" experience. Coverage for dependents is also available. Rates are based upon your age and the length of time you will be studying outside the USA.
Information Request Form (this is NOT an application for insurance): (return to top of page)
Use this form (please fill in ALL the blanks) to request rates via this Web page, or
Send e-mail inquiries to: , or:
Complete the form below to get a rate quote (please fill in ALL the blanks). Your personal information will be kept confidential and will NOT be sold or used for any other purpose.
NAME... first-middle-last.. your FULL name:
E-MAIL ADDRESS... essential:
GENDER: Male Female DATE OF BIRTH: mm/dd/yy
CITIZEN OF:
FULL HOME MAILING ADDRESS (include zip code):
STUDENT STATUS: -blank- Grad Student Senior Junior Sophomore Freshman
U.S. COLLEGE INFORMATION... (include name of school and city/state/zip of campus where you are a full-time student):
INTERNATIONAL SCHOOL ASSIGNMENT... (include name of school and city & country of campus you will attend overseas):
DATE OF DEPARTURE FROM THE USA: mm/dd/yy DATE OF RETURN TO THE USA: mm/dd/yy
SPACE FOR BRIEF REMARKS: (please use e-mail for more than 5 lines of visible text)
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