Proof of Insurance Coverage 5.18.22

Proof of Existing Insurance Coverage
Students are required to have comprehensive health coverage and may elect to buy a student health insurance policy provided by Cigna should they require it.

Students that already have existing comprehensive health coverage must submit this completed form and provide proof of current coverage.
Student Name*

First NameMiddle NameLast Name
Student ID Number
Student Email*
example@uhsa.edu.ag
Student Phone Number*
Please enter a valid phone number.
PLEASE CONTACT YOUR INSURANCE CARRIER TO CONFIRM THE INFORMATION FOR THE SECTION BELOW.
My existing coverage currently complies with the following requirements*

Medical and accident coverage up to $100,000 per accident or illness OR $200,000 minimum aggregateMaximum deductible of $500. For multiple party plans $500 per person.Policy covers office visits for non-emergency and emergency visits (No “Emergency Care Only” policies will be accepted).Maternity visits must be paid as any other health condition (N/A for males).Coverage includes medical repatriation coverage.
Insurance Carrier*
Policy Number*
Carrier Phone Number*
Proof of insurance*

Cancelof
Student attestation:
I have enrolled in the coverage specified on this form and attest to the accuracy of the information above. I will continue to maintain this coverage and will notify UHSA of any changes by submitting a new Proof of Insurance Evaluation Form as notification of those changes. Furthermore, I agree to submit a new Proof of Insurance Evaluation Form as periodically requested by UHSA, whether changes occur in my coverage or not. By signing below, I acknowledge that any fraudulent or misrepresented information herein will result in official student misconduct actions, which could result in suspension/dismissal from UHSA. Upon such findings, UHSA will have no responsibility (legal or financial) for any health issues that apply to and have been incurred by me, including death. By signing below, I also authorize UHSA to investigate the validity of private policy benefits to meet all listed requirements.
Signature*

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Date*

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Proof of Existing Insurance Coverage