Saint Louis University - Study Abroad

International Insurance Registration

Please fill out the form below. Once we receive your form, you will be enrolled in the International Insurance Plan through Saint Louis University. This insurance is mandatory but there is no charge to faculty or staff. The insurance has a $250 deductible (In other words, you will not be reimbursed the first $250 of your expenses).

* All Fields Required

INTERNATIONAL INSURANCE REGISTRATION FORM

Salutation:*

First Name:*

Middle Initial:

Last Name:*

Gender:*

Date of Birth:*

SLU Email Address:*

Your Cell Phone Number:*

SLU ID:*

Permanent Home Address:*

City:*

State:*

Zip Code:*

Home Phone Number:*

Status:*

Where Do You Live? (Country):* (i.e. USA)

What Country Are You Going?:*

Are You Going With or Leading a Group Abroad? If So, Name Group?:

Semester You're Going Abroad:* (i.e. Fall 2008)

Date of Departure:*

Date of Return:*

Emergency Contact:*

Relationship to You:*

Phone Number:*