UCI Insurance Services

Rates are $30 admissions Fee + $47 per month x 10 months = $500

Insurance application form

UCI TRAVEL INSURANCE SERVICES. International Student Insurance Application Form APPLICATION FORM Coverage is currently not available to insureds that reside in Washington and/or insureds traveling from outside the U.S. to Washington. 保险计划目前不提供给居住在华盛顿州的投保人和/或从美国以外到华盛顿州旅行的投保人。

Plan B ($300,000 per incident Medical Expense)
Fees $30 Admission fee + $470 /10 months = $500
Name of student*
FirstLast
Date of birth*
MM
DD
YYYY
Mailing Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Email 电子邮件*
Passport # *
Country issuing passport*
Country of Citizenship*
Visa type*
- F-1 Visa
- J-1 Visa
- Green card
Student type*
- I am an international student currently registered at a US school
- I am a student studying outside the US and registered at a US school
Insurance Coverage start date*
Arrival Date
Insurance end date*
Departure date
School Information
Name of school*
Location of school (state)*
Terms and conditions:
I hereby subscribe to the Group Insurance Trust and enroll in the group coverage for which I am eligible under the group contract issued by The Insurance Company of the State of Pennsylvania. All claims will be fully investigated. Premiums received by the Program Marketer/Insurance Company will be considered fully earned and non-refundable. I hereby certify that I have fully read, understand, and agree to the Study USA-HealthCare™ Insurance Brief Outline of Coverages.*
- I have read the terms and conditions and agree to Fees $30 Admission fee + $47 per month for term of insurance
Guardian Name*
FirstLast
Date*

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UCI Insurance Services

Insurance application form

Plan B ($300,000 per incident Medical Expense)

School Information

Terms and conditions:

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