I certify that I will attend one of the common programs listed on the health insurance price list. The amount listed for that program is

I certify that the program in which I will participate includes international health insurance coverage satisfying ODU's International Health Insurance Coverage Requirements for Study Abroad

I certify that I will attend a study abroad program that does not include international health insurance coverage satisfying ODU's requirements.

• My program start date is: Month January February March April May June July August September October November December Day 12345 678910 1112131415 1617181920 2122232425 2627282930 31 Year 20092010201120122013 20142015201620172018 20192020
• My program end date is: Month January February March April May June July August September October November December Day 12345 678910 1112131415 1617181920 2122232425 2627282930 31 Year 20092010201120122013 20142015201620172018 20192020
• My total program days are:  
• Including two travel days, I need   days of international health insurance coverage.
• At the current rate of   per day, my international health insurance will cost:  

Calculate

Total Health Insurance Cost:

I understand that, unless specifically exempt, I am responsible for purchasing international health insurance coverage through the ODU Office of Study Abroad at the above cost.

Student Signature:___________________________________________
Date:______________________________________________