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.
Spain students do not have to fill this form out.

The cost for the insurance is as following:

$20/Week - cash/checks payable to Saint Louis University
$75/Month - cash/checks payable to Saint Louis University
$250/Semester - billed directly to student account

All payments for weekly and monthly insurance rates must be sent/brought to:

Saint Louis University
Office of International Services
221 North Grand Blvd., DuBourg Hall 150
St. Louis, MO 63103

*All Fields Required

INTERNATIONAL INSURANCE REGISTRATION FORM

Type of Insurance: * Weekly Monthly Semester

Salutation:*

First Name:*

Middle Initial:

Last Name:*

Gender:*

Date of Birth:* (i.e. mm/dd/yyyy)

SLU Email Address:*

Your Cell Phone Number:* (i.e. xxx-xxx-xxxx)

SLU Student ID:*

Major(s) at SLU:*

Permanent Home Address:*
(this is where we will mail you your insurance card)

City:*

State:*

Zip Code:*

Home Phone Number:* (i.e. xxx-xxx-xxxx)

Status:*

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

What Country Are You Going?:*

Are You Going With A Group Abroad? If So, Name Group?:

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

Date of Departure:* (i.e. mm/dd/yyyy)

Date of Return:* (i.e. mm/dd/yyyy)

Group Coordinator:* (Faculty/Staff)

Coordinator's Department:*

Coordinator's Phone:*

Coordinator's E-mail:*

Emergency Contact:*

Relationship to You:*

Phone Number:* (i.e. xxx-xxx-xxxx)