Health Insurance Registration Form
Health Insurance cover for students applying to Ireland
Student Name Exactly as in Passport
*
First Name
Last Name
Agent Name
Student CNIC#
*
Student Passport#
*
Student Phone#
*
Student Phone Number
Student Address
*
Student own address only
Student Date of Birth
Enter Date of Birth written in student passport. If its entered incorrect policy will be void
Email ID of Student
*
Enter student Email ID to receive insurance at this email address
College/University student applied for
*
Mention name of Institution. Eg Griffith University Australia
Name of course
For example: MBA
Next to Kin/Sponsor Name
*
Name of Sponsor
Relationship with Sponsor
*
Relation with Sponsor
Type Of Health Insurance
*
United Insurance (local Insurance)
Study & Protect (International Insurance)
Student paid in local currency
Mention actual amount student / 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
Course Start date
*
Course end Date
*
Cost of Course
*
Upload payment receipt for Health Insurance
*
Browse Files
Upload receipt of Health Insurance payment Only
Cancel
of
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
Student Visa Current Status
will apply
Applied
Approved
Refused
Appeal
Other
Once visa decision arrive IEO staff will enter here
Office Remarks
Submit
Should be Empty: