Student Insurance Form

Health Insurance is required of all students taking 6 or more credit hours. Students (taking 6 or more credit hours) will be enrolled in the FBBC&TS Student Health Plan and will be charged for the school year premium unless you have an existing health plan that will provide adequate coverage while attending FBBC&TS. You may waive the school health insurance by submitting a copy of the front and back of your health insurance card. The school year premium will be added to your bill if you do not submit the Insurance card copy by the end of Orientation Weekend.

Student Information

Student First Name *

Last Name *

MI *

Cell Phone Number *

Birth Date * +

Email Address *

Ok to Contact You Via Email? *

Yes

No

Gender *

Male

Female

Street Address *

Apt/Unit Number

City *

State/Province/Region *

Zip/Postal Code *

Country *

I am an international student *

Yes

No

Home Country *

US Mailing Address *

Apt/Unit Number

City *

State *

Zip Code *

Student Social Security Number *

Passport Visa Type *

F1

J1

Other Other

Please indicate your insurance enrollment below. *

I do not have insurance and will enroll in Faith's Student Health Insurance.

I have my own Health Insurance and will provide a copy of my insurance card (both front and back).

___________________________________________________________________________________________________________

Front of Insurance Card

Back of Insurance Card

Below is the information on Faith's Insurance Plan. You will be required to select a plan in order to submit this form. The amount of the plan you select will be added to your school bill and is not able to have financial aid applied to it. If you have immediate questions, you may contact Kathleen at howellk@faith.edu.

SELECT THE COVERAGE YOU WISH TO PURCHASE AND CALCULATE THE TOTAL CHARGES: *

	ANNUAL 08/01/2021 to 07/31/2022 ($2,336.00)	FALL 08/01/2021 to 12/31/2021 ($980.00)	SPRING/SUMMER 01/01/2022 to 07/31/2022 ($1,356.00)	SUMMER 05/11/2022 to 07/31/2022 ($524.00)
Cost of Coverage	ANNUAL 08/01/2021 to 07/31/2022 ($2,336.00)	FALL 08/01/2021 to 12/31/2021 ($980.00)	SPRING/SUMMER 01/01/2022 to 07/31/2022 ($1,356.00)	SUMMER 05/11/2022 to 07/31/2022 ($524.00)

I certify that the information is complete and accurate to the best of my knowledge. I understand that in the event of illness or injury I am authorizing Health Services or a designated individual to give or obtain treatment. I will be financially responsible for any costs incurred.

Signature of Student *

clear

Date * +

If student is under 18, a parent’s or guardian’s signature below gives the Director of Health Services, Deans, or other designated individuals permission to give or obtain treatment for their son or daughter. I understand I will be financially responsible for any costs incurred.

Signature of Parent/Guardian

clear

Date * +

The information contained in this form is restricted for use by the Health Services Office and limited personnel at Faith Baptist Bible College and will not be released without the student’s knowledge or consent.