Insurance Waiver Template

Students who wish to waive UCI health insurance must submit this Waiver with their application. All
students who do not complete this Waiver by the program start date will automatically be enrolled in the
UCI health insurance plan, and will be responsible for paying those fees.
Please write clearly.
Family Name First Name
Telephone Email (required)
Preferred Street Address City
Country Postal Code
Select the program the applicant will attend
o Session I (June 22 - July 29) o 10-week Session (June 22 - August 28) o Session II (August 3 - September 9) o Session I and II (June 22 - September 9)
is waiver is to certify that I, the above named student, am waiving coverage of the health insurance plan oered to me
by the University of California, Irvine, University Extension Program in Summer Session (UCI UNEX), for coverage
during the above-specied program dates. In addition, because I am waiving the UCI UNEX health insurance, I am
guaranteeing that I will instead be covered by an independent health insurance plan which I will arrange myself. is
independent health insurance plan meets the following minimum required coverages.
$500,000 Maximum benefit per Policy Year
$25,000
Minimum coverage for Evacuation Expenses to your home country if necessary
$10,000 Minimum coverage for Repatriation of Remains to your home country in case of death
The deductible does not exceed $75.00 per injury/illness
I understand that during my program of study, adequate health insurance coverage, as dened by the minimum coverages
above, is required by UCI UNEX.
Insurance Company Name
Policy Number
Contact Phone Number
Coverage Dates
SIGNATURE DATE
2015 Deadlines to submit waivers: Session I: May 29 Session I and II: May 29 10-week: May 29 Session II: July 2
2015 UCI Summer Session
Health Insurance Waiver & Guarantee of Independent Coverage
PO Box 6050 Irvine, CA 92616-6050 Telephone (949) 824-4270 Email: internationalsummer.uci.edu
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