International Student Health Insurance

Instruction Sheet for Waiver For www.purdue.edu/PUSH

2010-2011 Academic Year
All international students are required to purchase the Purdue University sponsored health insurance plan as a
condition of enrollment and will not be permitted to waive the coverage. Very limited exceptions may apply for
students, who are covered under a government sponsor or a select U.S. or International Organization, or who are
covered as a U.S. based employee or a dependent of a U.S. based employee, with U.S. based health insurance provided
through that employee.

HOW DO I WAIVE OUT?

To WAIVE OUT of the University sponsored health insurance plan, international students must return the completed
Waiver form and supporting documentation to the Student Insurance Office no later than September 8th, 2010 for Fall
semester and January 31st, 2011 for the Spring semester. Failure to do so will result in loss of the waiver option and a
$200 late fee will be added to enroll in the Student Insurance plan. Insurance is mandatory and classes will be cancelled
if the health insurance requirement is not met.

WHAT MUST BE SUBMITTED?

1. Completed Waiver form
2. A letter on official letterhead from a government, U.S. or International organization, U.S. based employer,
or Health Insurance Company that will verify that the following minimum requirements are met:
st rd
 Coverage must be in effect from the 1 day of classes (August 23 ) through the last day of final exams
th
(May 7 ) or until employment ends.
 Medical benefits of at least $200,000 per accident or illness
 Repatriation of remains in the amount of $25,000
 Medical evacuation coverage in the amount of $50,000
 Annual deductible not to exceed $500 per illness per person
To qualify, an insurance policy must be underwritten by an insurance corporation with an A.M. Best rating of "A-" or above, an Insurance Solvency
International, Ltd. (ISI) rating of "A-I" or above, a Standard and Poor's Claims Paying Ability rating of "A-" or above, or a Weiss Research, Inc. rating of B+ or
above. Alternatively, the participant's policy may be backed by the full faith and credit of the government of the exchange visitor's home country.
The letter must reflect that all the above requirements are met or exceeded. A signature and contact phone
number must be included in the letter. Please include Student Name and PUID number. If repatriation and medical
evacuation coverage are not included, the requirement may be met by purchasing a separate policy at a cost of
$61.00 per year. Please see the Student Insurance Representatives in Room 340 of PUSH for more information. We
do not accept copies of insurance policies.
3. A copy of your I-94 document and Page 1 of your I-20 or DS2019
4. A copy of the front and back of your insurance card

HOW WILL I KNOW IF THE WAIVER HAS BEEN APPROVED?

By submitting the Waiver form, you are acknowledging that you are currently enrolled in one of the above stated health
insurance plans that will remain in effect throughout the 2010-2011 academic year or the entire time you are attending
Purdue University. Purdue University reserves the right to verify all information. All decisions of waiver approval or
denial will be communicated to you through your official Purdue e-mail account. If you have not heard from us within
two weeks of submitting all documentation, please email us at student-insurance@purdue.edu.
Use “WAIVER CONFIRMATION” as Subject line text. Please include Last Name, First Name and PUID number.

WHERE DO I SUBMIT THE WAIVER FORM?

Please submit all documents at the same time to the Student Insurance Office. These include the completed Waiver
form and all supporting documentation.
In Person: Purdue University Student Health Center, Room 340
By Mail: PUSH Student Insurance Office, 601 Stadium Mall Drive, West Lafayette, IN 47907
By FAX: 765-496-2524 By Email: student-insurance@purdue.edu

Note to Degree or Exam Only Students: You must still meet the requirement for having insurance coverage for the entire academic
semester. However, if you are on OPT, you will be exempt from showing proof to Purdue. It is important that you enroll in your
company’s health insurance plan while in the U.S. Contact the Student Insurance Office if you anticipate any lapse in coverage.
 PURDUE MANDATORY HEALTH INSURANCE WAIVER FORM
(For International Students Only – Do not use this form if Exchange Student)
Waiver Submission DEADLINE: SEPTEMBER 8th, 2010 (Spring Deadline: January 31st , 2011)
This form is required for each academic year.
FAILURE TO COMPLY WITH THIS DEADLINE WILL CAUSE ALL CLASSES TO BE CANCELLED AND PLACE A STUDENT’S LEGAL STATUS AT RISK.

Section I: Student Information (all information required)

PUID#:_____________________
_____________________ _____________________ _____ ______/______/_____
Last Name First Name M.I Date of Birth ( Month/Day/Year)
______________________________________________ ____________
Local Street Address Apartment Number
_________________________ ________________ __________ ( )____________
City State Zip Code Telephone Number
___________________________________________ ______________________________
Purdue E-mail Address (required) College Major or School (ex. Science, Engineering)

Section II: Insurance Information

I certify that I will have health insurance under one of the following throughout the 2010-2011 academic year:
Please check appropriate box.

I am fully sponsored by my home government and my government has purchased my health

insurance (not just supplied funds to purchase an insurance plan of my choice)
Example: Government of Kuwait
**************************************** ****************************

I am fully financially sponsored by a U.S. or International organization (including tuition, living

expenses, medical expenses, health insurance plan, etc) These include: Fulbright, IIE, LASPAU,
USAID, WHO, Rockefeller, ARAMCO, SABIC
********************************************************************

I am covered as a U.S. – based employee, or as a dependent of a U.S. based employee, under U.S.
based health insurance provided through that employment. Name of Employee:__________________
Yes No My US based policy includes minimum coverage of $25,000 for medical evacuation and $50,000
for repatriation of remains. (If not included, this is available for purchase at a cost of $61.00 per year – Contact Student
Insurance representative).

NOTE: No socialized/standard medical policies, including Canadian, French, German, Australian policies will be accepted.

Please attach a copy of the following three items with this request:
1. Written verification on official letterhead of health insurance coverage from a government, U.S. or International
organization, or U.S. based employer. (See instruction sheet.)
2. A copy of your most current I-94 document and a copy of Page 1 of your I-20 or DS2019.
3. A copy of your insurance card, front and back

Please allow 1-2 weeks for processing. You will be notified of the decision via your Purdue email account.
Please keep a copy of this form (and any supporting documents) for your records.

X_____________________________________________________________________ _______/______/_______
Student / Scholar Signature of Understanding Date (Month/Day/Year)

Return to:
Purdue University Student Insurance Office
601 Stadium Mall Drive Room 340
West Lafayette, IN 47907-2052
Phone: (765) 496-3998 Fax: (765) 496-2524 Rev. 2.10.10