Student Accident & Sickness Waiver Form

Students that have comparable insurance coverage and choose to waive the medical insurance policy offered through Lawrence University must complete this form. If you do not have comparable insurance coverage, you will be automatically billed by the school and covered. THE WAIVER DEADLINE FOR FALL TERM IS AUGUST 1.

Complete and return this electronic form or mail to:
International Student Services | 711 E. Boldt Way, SPC 41 | Appleton, WI 54911 | Fax: 1‐920‐832‐7026;
Email: internationalhouse@lawrence.edu

LU ID Number

First

Middle

Last

Suffix

Date of Birth

Address

Student Personal Email Address

Insurance Company

Please check the box to confirm that you have comparable coverage that covers your health expenses incurred inside the United States.

Insurance Company Address

Insurance Policy Number

Insurance Deductible

A deductible is the amount of money (ranging from $0 - $1000+) an individual pays for expenses before his insurance plan starts to pay. Your insurance company should tell you what the deductible for your plan is.

My insurance policy meets the minimum health insurance requirements recommended by the Department of State (see requirements below).

Yes

Medical benefits of at least $100,000 per accident or illness.
Repatriation of remains in the amount of $25,000.
Expenses associated with the medical evacuation of the student his or her home country in the amount of $50,000.
A deductible not to exceed $500 per accident or illness.
A policy covering the academic year AND the summer if you will be staying in the United States.
An insurance policy secured to meet the benefits requirements 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 sponsor may ascertain that the participant's policy is backed by the full faith and credit of the government of the exchange visitor's home country.

Please upload a copy of your insurance card

One file only.
100 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Please upload a copy of what your insurance policy covers

Electronic Signature

I am electronically signing this form to waive Lawrence University’s health insurance coverage and confirm that I will be outside of the United States with health coverage in my home country or I hold my own insurance that is comparable to the LU insurance and covers the following:

Medical benefits of at least $100,000 per accident or illness.
Repatriation of remains in the amount of $25,000.
Expenses associated with the medical evacuation of the student his or her home country in the amount of $50,000.
A deductible not to exceed $500 per accident or illness.
A policy covering the academic year AND the summer if you will be staying in the United States.
An insurance policy secured to meet the benefits requirements 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 sponsor may ascertain that the participant's policy is backed by the full faith and credit of the government of the exchange visitor's home country.

Signature Date

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