ISO

1 Personal Information

For questions about the insurance plan or waiver process, please contact ISO at (800) 244-1180 or customercare@isoa.org. Office hours are Monday to Friday, 9am to 6pm EST.

Student Personal Information

First name

Last name

E-mail address

Gender

Male Female

Date of birth

Student ID or passport number

U.S. Contact Information

U.S. Address

Zip code

City

State

Address

Address (optional)

Phone number (mobile)

Phone number (home)

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2 Alternate Insurance

Please note: The university and its agents have the right to audit and confirm your policy and coverage information.

Full name of insurance company

Insurance company address

Insurance company phone number

Your policy effective date

Your policy termination date

Your policy number

Is the insurance company operating in the US with a US claims address and accessible customer service telephone number?

Yes No

Relationship to policyholder

Self Parent Spouse Guardian Employer

First name of policyholder (If "self" - please provide your first name)

Last name of policyholder (If "self" - please provide your last name)

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3 Insurance Benefits

Does your insurance provide the following benefits:

Coverage for lab tests and X-rays?

Yes No

Coverage for prescription drugs?

Yes No

Coverage for hospitalization (including room & board, physician fees and surgical expenses)?

Yes No

Coverage for outpatient hospital services?

Yes No

Mental health benefits?

Yes No

Coverage of Emergency Room care?

Yes No

A deductible not to exceed $500 annually?

Yes No

Per injury maximum of at least $250,000 with no lifetime maximum?

Yes No

Maximum out-of-pocket expenses $6,000 annually?

Yes No

Repatriation coverage of at least $25,000?

Yes No

Medical evacuation coverage to home country at least $50,000?

Yes No

Co-Insurance in-network of at least 80%?

Yes No

No exclusion for pre-existing conditions?

Yes No

A U.S. Insurance Carrier having an A.M. Best rating of "A-" or above; a McGraw Hill Financial/Standard & Poor Claims-paying ability rating of "A-" or above; a Weiss Research, Inc. rating of "B+" or above; a Fitch Ratings, Inc. rating of "A-" or above; a Moody Investor Services rating of "A3" or above; or such other rating as the U.S. Department of State may from time to time specify.

Yes No

Reason for waiving insurance

Waiver form is completed by (Type name):

By submitting this waiver request, I understand that I am requesting not to be enrolled in the health insurance offered by ISO and DePaul University and the waiver is ONLY VALID for academic year 2023 - 2024. I understand that I am responsible for submitting documentation to prove I have an alternative insurance plan that meets the waiver requirements listed above. Furthermore, I understand the risks involved by declining the ISO insurance plan and opting for my own insurance plan.

I know the University and/or its agents has the right to request in writing evidence of health insurance coverage. Evidence of such coverage can be furnished by submitting the front and back of your health insurance ID card, a copy of the insurance policy and a letter from the insurance company confirming coverage is in effect during your period of enrollment.

If you have any questions, please contact ISO at (800) 244-1180 or customercare@isoa.org

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