Insurance Waiver Form - University of Florida

International Student Services
1764 Stadium Road, Suite 170 HUB. PO Box 113225
Gainesville, FL 32611-3225
Phone: 352-273-1540
Fax: 352-392-5575
The Foundation for The Gator Nation
Rev. Oct-13
An Equal Opportunity Institution
Health Insurance Waiver Form
Submit form via email to: in[email protected]fic.ufl.edu
It is a Florida State University System’s Board of Governors (BOG) requirement that all international
students have health coverage at all times while in the United States. If you are going to be in the United
States for any part of a term, you must be covered by health insurance for that entire term. This is also
for your benefit, as the cost of minor health problems can be far greater than the cost of health
insurance. Please read, complete and email this form to the above email address.
Last Name First Name UFID Telephone Number
E-Mail College Major Degree Level
SELECT ONLY ONE OF THESE OPTIONS TO REQUEST A WAIVER FOR THE SUMMER TERM
Option 1: If you expect to graduate in the Spring term: your Academic Department official and you
must complete the first section of this form. In this case, your I-20 will be shortened to the expected
graduation date.
For the ACADEMIC ADVISOR, GRADUATE CHAIR, DEAN, etc. to complete:
I confirm that the above mentioned student is expected to complete all degree requirements and
GRADUATE in the SPRING __________ semester.
________________________________________________________ ________________________________________
Academic Department Official’s Signature Date
________________________________________________________ ________________________________________
Academic Department Official’s Name Telephone Number
For the student:
I understand my I-20 will be shortened to the expected graduation date. If I do not graduate, it will
be my responsibility to request an I-20 extension prior to the expiration date. I will be required to
provide proof of funds and of insurance at the time I request the I-20 extension.
_________________________________________________ ________________________________________
Student’s Signature Date
Option 2: If you do not expect to graduate in the Spring term, but will not be in the US during the
Summer term: you, as the student, must complete this section of the form. You must also provide a
copy of your flight itinerary showing that you will not be in the U.S. during the summer period. Please
refer to ufic.ufl.edu/ISS/insurance.html for the summer dates.
By signing this form, I confirm that I will NOT be in the United States during the ENTIRE SUMMER
semester. I am providing a copy of my flight itinerary with this form.
_________________________________________________ ________________________________________
Student’s Signature Date
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Insurance Waiver Form - University of Florida PDF

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