Health/Accident Insurance Form

State College of Florida
International Students On F-1 Student Status

International students on F-1 student status shall not be permitted to register or be permitted to continue enrollment at the State College of Florida unless they demonstrate that they have adequate medical insurance coverage for illness and injuries in the United States.

Insurance proceeds may not be restricted to a specific institution, clinic, health care entity or locale, and the provider must have a claims office in the United States.

All full-time F-1 international students enrolled at the State College of Florida must fulfill this regulation. Please carefully read and complete the following:

I HAVE READ THE COLLEGE'S REGULATION ABOVE WHICH STATES THAT I MUST HOLD MEDICAL AND ACCIDENT INSURANCE IN ORDER TO BE ENROLLED FULL-TIME AT THE STATE COLLEGE OF FLORIDA.  IN ORDER TO FULFILL THIS REGULATION, I HAVE PURCHASED THE FOLLOWING INSURANCE POLICY:

NAME OF INSURANCE COMPANY:  _______________________________________________

POLICY NUMBER: ________________ POLICY EXPIRATION DATE: _____________

I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE-MENTIONED COLLEGE REGULATION, AND THAT I HAVE PURCHASED HEALTH/ACCIDENT INSURANCE, AND THAT I WILL CONTINUE TO MAINTAIN HEALTH/ACCIDENT INSURANCE AS LONG AS I AM A STUDENT AT THE STATE COLLEGE OF FLORIDA.  I FURTHER CERTIFY THAT THE INFORMATION GIVEN ABOVE IS COMPLETE AND ACCURATE, AND I UNDERSTAND THAT MAKING FALSE OR FRAUDULENT STATEMENTS ON THIS FORM MAY RESULT IN CANCELLATION OF REGISTRATION.

NAME (type or print): _________________________________________________

SCF STUDENT NUMBER: G00 - __________ PHONE NUMBER: _________________

SIGNATURE: _________________________________________________________
            

DATE:  ________________________ E-MAIL ADDRESS: _____________________

This Health/Accident Insurance Form should be on file in the Educational Records Office after the I-20AB has been issued AND BEFORE THE FIRST DAY OF CLASS.  Failure to do so will prevent any future class registration until this form is submitted and approved.