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ODU International Health Insurance Coverage Certification Form

Please fill out the following form. Print the form, sign and date it, and turn it in with your payment to the Office of Study Abroad.

Following submission of this form, please allow 10 business days for processing.

Old Dominion University policy #5101 requires that all students, faculty, administrators and staff participating in international education abroad initiatives -- whether of a credit or non-credit nature -- carry complete international health insurance coverage for the duration of their program.

Name:
UIN:
Program Name:
DOB (mm/dd/yyyy)
Telephone #
Email Address
Physical Address

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:
My program end date is:
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:

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:______________________________________________

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	Spring Break and Summer Programs for 2012!
	Information Sessions
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	How to Fund Your Study Abroad Experience
	Student Fellowships for International Study/Research
	Passport Application Information
	Travel Information
	CDC Travelers' Health Information
	Digest for Student Funding/ Job Opportunities and Conferences
	International Career Advantage Program
	Forms

	STUDY ABROAD: ODU students speak on their experiences
	View ODU students' photographs from abroad
	Student blog: Michelle Tisch at the University of Leicester
	Student blog: Stephen Benkert in Melbourne, Australia
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	See a YouTube video of one study abroad student's experience

	Mission Statement
	Frequently Asked Questions
	Interest Form
	Contact Us




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