Summer School Health Insurance
Please fill out the following for to be enrolled in our international student insurance plan for your program at Michigan State University. If you have any questions, please contact us at vippmsu@msu.edu.
Full Name
*
Prefix
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Date of Arrival in the US (This will serve as your coverage start date. All summer school programs start July 17th 2018)
*
-
Month
-
Day
Year
Date
Alternative date to begin coverage (If you plan on arriving before the 17th)
-
Month
-
Day
Year
Date
End trip date (This will serve as your coverage end date. Transportation Engineering ends on August 7th 2018, all other programs end on August 8th 2018)
*
-
Month
-
Day
Year
Date
Is your destination East Lansing, MI? If no, please specify elsewhere in the next box
*
Yes
No
If answer above is no:
Number of days for coverage
*
Submit Form
Should be Empty: