Insurance Waiver Form
AFLI Overseas Program Insurance Waiver Participant Full Name: ______________________________
Home Institution:
Period of Study: I acknowledge that I have been offered the opportunity to purchase Cultural Insurance Services International (CISI) coverage from American Councils for International Education. I decline enrollment at this time because: I have other medical coverage provided by: Cultural Insurance Services International (CISI) Policy no.: ____________________________
By signing below, I understand that I am opting out of the insurance provided by American Councils for International Education. I certify that my current CISI health insurance coverage meets or exceeds the minimum coverage provided by CISI through American Councils. I understand that the sole purpose of American Councils’ review of this information is to determine if I qualify for a waiver of insurance, which is required prior to my participation in the African Flagship Languages Initiative (AFLI) Overseas Program. I certify that my insurance coverage is in effect and will remain in effect for the entire AFLI Overseas Program period for which I am requesting this waiver. I understand that it is my sole responsibility to maintain the minimum coverage required by applicable federal regulations. I further understand that failure to maintain comparable coverage upon which a waiver is granted is a violation of policy and that failure to maintain the required minimum may result in revocation of my admission to the AFLI Overseas Program. I certify that I am legally responsible for my own medical expenses and that American Councils is not responsible for such expenses.
Participant Signature: _________________________________ Date: _____________________
Home Institution:
Period of Study: I acknowledge that I have been offered the opportunity to purchase Cultural Insurance Services International (CISI) coverage from American Councils for International Education. I decline enrollment at this time because: I have other medical coverage provided by: Cultural Insurance Services International (CISI) Policy no.: ____________________________
By signing below, I understand that I am opting out of the insurance provided by American Councils for International Education. I certify that my current CISI health insurance coverage meets or exceeds the minimum coverage provided by CISI through American Councils. I understand that the sole purpose of American Councils’ review of this information is to determine if I qualify for a waiver of insurance, which is required prior to my participation in the African Flagship Languages Initiative (AFLI) Overseas Program. I certify that my insurance coverage is in effect and will remain in effect for the entire AFLI Overseas Program period for which I am requesting this waiver. I understand that it is my sole responsibility to maintain the minimum coverage required by applicable federal regulations. I further understand that failure to maintain comparable coverage upon which a waiver is granted is a violation of policy and that failure to maintain the required minimum may result in revocation of my admission to the AFLI Overseas Program. I certify that I am legally responsible for my own medical expenses and that American Councils is not responsible for such expenses.
Participant Signature: _________________________________ Date: _____________________
