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    Insurance

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    aptureinc
    This document is a proof of insurance form from Middle Tennessee State University's International Programs and Services Office. It requires the student's name, insurance policy number, insurance company name, and confirmation that the policy covers sickness, hospitalization, doctor's visits, medical evacuation, and repatriation of remains while abroad. The student must also indicate their insurance carrier's procedure for handling claims overseas, such as requiring the student to pay upfront and submit receipts for reimbursement. The form must be signed and returned to the International Programs and Services Office.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Insurance

    Uploaded by

    aptureinc
    59 views1 page
    This document is a proof of insurance form from Middle Tennessee State University's International Programs and Services Office. It requires the student's name, insurance policy number, insurance company name, and confirmation that the policy covers sickness, hospitalization, doctor's visits, medical evacuation, and repatriation of remains while abroad. The student must also indicate their insurance carrier's procedure for handling claims overseas, such as requiring the student to pay upfront and submit receipts for reimbursement. The form must be signed and returned to the International Programs and Services Office.

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    This document is a proof of insurance form from Middle Tennessee State University's International Programs and Services Office. It requires the student's name, insurance policy number, insurance company name, and confirmation that the policy covers sickness, hospitalization, doctor's visits, medical evacuation, and repatriation of remains while abroad. The student must also indicate their insurance carrier's procedure for handling claims overseas, such as requiring the student to pay upfront and submit receipts for reimbursement. The form must be signed and returned to the International Programs and Services Office.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    59 views1 page

    Insurance

    Uploaded by

    aptureinc
    This document is a proof of insurance form from Middle Tennessee State University's International Programs and Services Office. It requires the student's name, insurance policy number, insurance company name, and confirmation that the policy covers sickness, hospitalization, doctor's visits, medical evacuation, and repatriation of remains while abroad. The student must also indicate their insurance carrier's procedure for handling claims overseas, such as requiring the student to pay upfront and submit receipts for reimbursement. The form must be signed and returned to the International Programs and Services Office.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    MIDDLE TENNESSEE STATE UNIVERSITY

    International Programs and Services Office


    Proof of Insurance

    Name: Program ____________________________

    This is to state that policy number: ____________ has been issued to ________________

    by _______________________________________________________________________
    (Name of Insurance Company)
    providing insurance protection for medical emergencies during travel abroad. This policy will
    be in full force and effect during the time of enrollment in your study abroad program.

    Does the above policy cover Sickness/hospitalization? ____yes ____no


    these expenses incurred in Doctor’s visits ____yes ____no
    another country? Medical evacuation ? ____yes ____no
    Repatriation of remains? ____yes ____no

    *Please indicate your medical insurance carrier’s procedure for handling claims in the event
    that you require medical care while overseas:
    ____ I must pay cash to service provider and submit paid receipts to insurance company for
    reimbursement.
    ____ The insurance company will deal directly with medical service provider in another
    country.

    _______ I am not covered by private insurance and will accept the minimum coverage offered
    by the International Student Identity Card (see Part I of the Information Packet).

    _________________________________________________ _____________________
    Participant’s Signature Date

    * It is important to be aware of what procedures for payment/reimbursement will be required


    by your particular medical insurance company. Most U.S. companies will not make payment
    directly to a foreign doctor or hospital. In the event of illness or accident, students must be
    prepared to pay cash to the foreign doctor or hospital, and be responsible for obtaining
    receipts to submit for reimbursement by their U.S. medical insurer. BE PREPARED BY
    KNOWING YOUR INSURER’S GUIDELINES!

    Please Return Form to the International Programs and Services Office in the Cope
    Administration Building Room 202.

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