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Stetson University Deland International Students Insurance Opt-Out Waiver Form

Stetson University Deland International Students
Insurance Opt-Out Waiver Form
(mm/dd/yyyy)

Please Answer the Following Questions
1. Do you have a plan that will provide coverage for sickness and accident with local physicians, hospitals, pharmacies, and mental health care providers in the Stetson University/Central Florida area?
2. Do you have a plan that will provide coverage for the entire academic year?
3. Do you have a plan that provides a coverage limit of at least $50,000 per injury/accident?
4. Do you have a plan that provides coverage for lab work, diagnostic x-rays, physical therapy, and prescriptions in the Stetson University/Central Florida area?
5. Do you have a plan that provides the Policy provisions in English?
6. Does your plan have a United States Claims Agent and are insurance proceeds payable in U.S. dollars?
7. Does your plan provide at least 75% coinsurance coverage and a deductible no greater than than $500?
8. Does your plan include Medical Evacuation and Repatriation of Remains equal to or greater than the current U.S. Dept. State requirements?
9. Does your plan allow coverage for pre-existing medical conditions?
If you answered “no” to any of the above, you will be required to enroll in the campus student insurance plan. Note: If required to enroll in the Campus Student Insurance Plan in addition to what you may already have, the Campus Student plan can also act as a secondary insurance to cover some of the benefits that your current plan may not cover.

Current Health Insurance Plan Information
(typically found on your insurance card)
Claims
Primary Insured
(mm/dd/yyyy)
(mm/dd/yyyy)
Must be located in the U.S.
As listed on Insurance ID Card

Opt Out Eligibility Requirements

To indicate your acknowledgment of the following requirements, please click the checkbox to the left of each item:

You are currently covered by the above insurance policy;
Your plan is NOT a travel or emergency-only type plan;
If your plan has a deductible in excess of $250, you have adequate financial resources available to pay for the charges under the deductible;
You have verified with you health insurance representative that your plan provides sickness and accident coverage in the Stetson University/Central Florida area.
If the above policy is terminated, you will be required to enroll in the campus plan. Should this happen, please contact Insurance For Students at This email address is being protected from spambots. You need JavaScript enabled to view it. or call 1-800-356-1235.
Note: You must provide a copy of your insurance card and a copy of your
policy or policy declarations page with summary of benefits.
Please Mail, Fax or Email to: Fran Buit, Insurance for Students
600 Corporate Dr, Ste 101
Ft. Lauderdale, FL 33334		 Fax: 954-772-0872
Phone: 800-356-1235
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

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