International Student Medical Insurance Verification Important: All international students are required to purchase a student health insurance plan as a condition of enrollment at ULACIT

Personal Information

First Name ____________________ Middle Name__________________ Last Name _____________________

Passport/ID Number___________________________

Date of Birth (month/day/year) ( / / ) Personal Email address_______________________

Home University’s Name________________________ University’s Phone Number_____________________

University International Department contact name _______________________________________________

E-mail address_________________________________________________

Medical Insurance Verification

Insurance Carrier Name____________________ Insurance ID Number__________________________

Insurance Emergency Phone Number___________________ Insurance Plan Name__________________

Insurance E-mail _______________________________________

In case of Emergency, please contact:

Name ______________________________ Relationship _______________________

Address________________________________________________________________________________

City /State___________________________________________ Country____________________________

Business E-mail address___________________________ Personal E-mail___________________________

Home Phone Number__________________________Cell Phone Number___________________________

I certify that I am currently enrolled in a health insurance plan (no travel insurance policies are accepted), that will remain in effect throughout my entire term(s) at ULACIT from: ____/_____/_____ to _____/_____/_____ and that I am solely and fully financially responsible for all medical expenses. I understand that the information provided herein is confidential. Furthermore, I am assured that this information will not be made available to any third party outside the Global Education Office at ULACIT.

Important: Please attach a copy of your health insurance ID card or written verification of coverage and keep a

copy of this form for your records. Please send this form thoroughly filled out to: vcastro@ulacit.ac.cr The information in this document may be verified at any moment during the enrollment process. Illegible forms will be sent back. We advise applicants to fill it out using Microsoft word and print it only

to be signed (this form is expected to be sent in PDF format).

Student’s signature: __________________________________ Date (mm/dd/yy): ________________________