International Health Insurance Enrollment Form

This form should be used by the following groups who would like to purchase international health insurance through the SUNY United Healthcare Insurance plan. The coverage includes Medical, Security & Natural Disaster Evacuation and Repatriation.

- OPT Students
- J1 scholars
- Campus faculty/staff travelling overseas on university business.
- Students travelling overseas for research or a conference (not enrolled in a study abroad program).

Name Name First Last
Banner ID

This will be your ID number for your insurance
Email
I am:

I am: F-1 Brockport Student on OPT J-1 Researcher, Professor, or Scholar Faculty or student travelling abroad (i.e. research, conference)
Your Coverage Dates

Please enter the dates of your departure from the US and return the US. Our team will use these to formulate a quote for you, if applicable.
Request Coverage Start Request Coverage Start / MM / DD YYYY
Requested Coverage End Requested Coverage End / MM / DD YYYY
Enrollment Information
Gender

Gender Male Female
Date of Birth Date of Birth / MM / DD YYYY
Address in USA Address in USA
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
J-2 Insurance

If you have any Spouse or Dependents coming as J-2 Visitors who will need insurance, you will be able to enroll them through your online portal.

International Health Insurance Enrollment Form

Your Coverage Dates

Enrollment Information

J-2 Insurance