Franklin University International Student Medical Insurance Plan
Insurance Waiver Petition
2012-2013 Academic Year

Insurance Information

I do not wish to purchase the Franklin University International Student Health Insurance Plan for 2012-2013. In submitting this Insurance Waiver Petition, I fully understand that it is my responsibility to maintain health insurance for myself and my family (if applicable).

Please answer the following questions to determine if your current coverage exempts you from purchasing the school's recommended insurance coverage.

My plan is a group major medical plan provided by my parents, my sponsor, my employer, or my spouse’s employer/university.
My plan provides a minimum of $250,000 reimbursement per illness or accident for each insured person.
My plan is currently in force and will remain in force until August 15, 2013 (or beyond).  Further, I understand that if this Insurance Waiver Petition is accepted by Franklin University, my insurance company may be contacted to confirm continuous coverage on a periodic basis.
I request waiver out of the Franklin University International Student Health Insurance Plan for 2012-2013 because of extenuating circumstances or a Pre-existing Condition (submit).
My plan will cover me during a Break Term (as defined and approved by Franklin University).
My plan includes repatriation of remains coverage of a least $10,000.00.
My plan includes medical evacuation coverage of at least $10,000.00.
My plan is underwritten by a company licensed to do business (or domiciled) in Ohio.
My plan is administered by an insurance company with a licensed claims office in the United States, and this claims office has a toll free telephone line for claims inquiries.
My plan is underwritten by an insurance company having an A.M. Best rating of "A-" or above, a Standard & Poor's Claim Paying Ability rating of "A" or above, or a Weiss Research, Inc. rating of "B+" or above.


You must send a copy of your Insurance ID Card to the Harbour Group by fax (937‑885‑5380), by email (info@hginsurance.com), or by mail to:

The Harbour Group
66 Remick Blvd.
Springboro, OH  45066

Phone 1-800-252-8160

I understand that authorizing this Insurance Waiver Petition is in the sole and final discretion of Franklin University.  If the Waiver is authorized, I release Franklin University from any liability for any issue of medical coverage.

I confirm that I have read and accept all of the provisions of the plan,
as stated in this document.