International Health Insurance Registration Form
Health insurance coverage for students applying to study in Ireland, as well as for graduates currently residing in Ireland who require insurance for their Stamp 1G renewal.
Student Name Exactly as in Passport
*
First Name
Last Name
Agent Name
For Example: Ireland Education Office
Student ID Card#
Student Passport#
*
Email ID of Student
*
Enter student Email ID to receive insurance at this email address
Student Phone#
*
Student Phone Number
Student Date of Birth
*
Enter Date of Birth written in student passport. If its entered incorrect policy will be void
Student Address
*
Student own address only
College/University student applied for or graduated from
Mention name of Institution. Eg Griffith University Australia
Name of course
For example: MBA
Next to Kin Name
*
Name of Any Relative
Relationship with Next to Kin
*
Relation with Next to Kin
Type Of Health Insurance
*
Medicover Standard for Graduate 1G Stamp (259 Euro)
Medicover Standard for Visa Purpose (170 Euro)
Student paid in local currency
Mention actual amount Paid / agent paid to IEO for this policy
How student / Office paid to IEO
Cash
Bank Transfer
Credit Card
Adjustment
Other
Mention if you paid via Bank deposit or else.
Mode Of Payment
Cash at office
Online in Bank
Adjustments
Other
Cover Start date
Cover end Date
Cost of Course
Not Required for Graduate Policy
Upload Your Passport
*
Browse Files
Upload Passport Copy
Cancel
of
Upload payment receipt for Health Insurance
*
Browse Files
Upload receipt of Health Insurance payment Only
Cancel
of
I Certify and Agree that
*
Insurance payment is non-refundable once the policy has been purchased/issued.
For Office Use only
IEO staff will enter below details. Agent / Student leave these blank when ordering policy
Upload Insurance policy
Browse Files
Once issued IEO staff will upload policy doc
Cancel
of
Office Remarks
Submit
Should be Empty: