International Student Insurance Plan Waiver Request Form

All F1 and J1 visa students are required to purchase health insurance provided by LewerMark Student Insurance. You will be billed for the insurance at the beginning of each semester or year. Students who request a waiver of the mandatory insurance must demonstrate that they have comparable insurance coverage each semester. To petition for a waiver, students must follow the procedures outlined below. A new waiver form must be completed each semester. For questions regarding this waiver request form or the insurance policy for F1 and J1 visa students, please contact Michael Fekete in the International Student and Global Scholars Services Office.

Eligible Waiver:
  • Sponsored by a Government Scholarship (Fulbright or SACM)
  • An employer plan who is currently on CPT/ OPT
  • A family member working for a U.S. employer with insurance
Non-Eligible Waiver:
  • Waivers are not acceptable for individual plans purchased in the United States
  • Travel Insurance or Emergency Only plans will not be accepted.
Waiver Procedure:
Each semester or year, the cost for the health insurance will be charged to each F-1 and J-1 visa holder’s school account.
      • Semester charge: $154.11 per month
  • Coverage dates: 08/01 to 12/31 for Fall Semester and 01/01 to 05/31 for Spring Semester
  • Deadline for waiver: 10 days after the set International Students Orientation Program date

Students who receive a waiver will be notified by email and will have the insurance charge removed from their account.

Along with this form, you will need to summit your full policy with all benefits & exclusions shown. The alternative policy must:

  • Be written in English
  • Be converted to U.S. dollar currency
  • Provide comparable coverage for the following but not limited to:
    • Mental Health: 30 days outpatient, 30 days inpatient
    • Pre-Existing Conditions: coverage up to the policy max after 6 months
    • Annual Maximum: $250,000 USD
    • A deductible not greater than $500
    • At least $25,000 USD for repatriation
    • At least $50,000 USD for medical evacuation
  • Provide continuous coverage during academic semesters and University breaks and vacation periods

Waiver request for Student Insurance:

*Term:    Year:

*Student Last Name:


*Student First Name:


*Student ID Number:


*Student Email address:


*Local Phone Number:


Visa Type: 
F-1
J-1

Reason for waiver request (choose one): 
Sponsored by a Government Scholarship (Fulbright or SACM)
An employer plan who is currently on CPT/ OPT
A family member working for a U.S. employer with insurance


Alternative Insurance Information (see Page 1 for alternate insurance requirements)

Name of Insurance Carrier:


Policy Number:


Address of Carrier:


Start Date of Coverage:
   

End Date of Coverage:


Amount of Annual Coverage:


Amount of Coverage for Repatriation:


Amount of Coverage for Medical Evacuation:


Amount of Coverage for Mental Health:


(If there would become a medical or mental health situation that would be long lasting, travel back to Sweden is covered by the insurance as well.)
Is Policy in English?


Customer Service Phone Number:


Name of Policy Owner (Primary Insured Person):


I understand that:
  • A denied waiver request OR failure to provide complete and accurate information will result in my automatic enrollment in the LewerMark international insurance policy.
  • If my insurance coverage ends for any reason, it is my responsibility to notify the International Students Office.
  • Any medical expenses I incur in excess of my insurance coverage are my responsibility and Lewis University assumes no liability.
Signature:


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