Eastern Kentucky University

Office of International Student and Scholar Services

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Health Insurance Waiver Form

Please fill out the form below completely, and submit it along with the required documents to the Office of International Student and Scholar Services (OISSS) before the deadline. Incomplete waiver applications will be rejected. Do not wait for the deadline! Your application will be reviewed within 5-7 business days of submission.

STUDENT'S PERSONAL INFORMATION

Full Name *

EKU ID Number *

Street Address *

Apartment, suite, etc.

City *

State/Province *

ZIP / Postal Code *

Country *

Phone Number *

Email Address *

Current Visa Status *F-1J-1Other

If you selected "Other" enter visa name here

REASON FOR WAIVER REQUEST

I am requesting a waiver from the EKU International Student Health Insurance requirement because I am...An athlete, and my health insurance is covered by the EKU Athletics Department.A student sponsored, by my government, including health insurance benefits.A student sponsored, by the U.S. government, an international organization or exchange program (such as Fulbright, International Institute of Education (IIE) etc.).Receiving health insurance benefits provided by my parent, spouse or partner’s U.S. employer.

HEALTH INSURANCE INFORMATION

Name of Insurance Company *

Is this a U.S. based Insurance Company?YesNo

Beginning Date of Coverage *

Year

Month

Day

Ending Date of Coverage *

Year

Month

Day

Copy of Health Insurance ID Card *

No file chosen

Copy of Scholarship Letter (for sponsored students only)

No file chosen

By submitting this form, I certify that I have ready all of the waiver requirements, policy, and procedures listed on OISSS website and on this waiver request form and agree to abide by them. By agreeing and submitting this form, I acknowledge that the information above is true and accurate and I understand that I must carry health insurance as long as I am enrolled at EKU.

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