Health Insurance Waiver Form

All international students are required to purchase and subscribe to the health insurance plan selected by the San Jose/Evergreen Community College District. San Jose City College does not accept any other U.S. or foreign-based insurance plans. Only students who meet the following eligibility requirements may obtain a waiver. To obtain a health insurance waiver complete this form and provide the required documents to the International Student Program (ISP) office by the first day of each semester.

Waiver Eligibility: The international student has a spouse, domestic partner, or parent who is employed by a U.S. company and has active health insurance coverage. The following documents need to be submitted with this waiver form:

• Proof of relationship to insured person (e.g. Marriage/ birth /domestic partnership certificate )
• Copy of insurance card (front & back)
• Proof of the student's name on the same insurance plan.
• Copy of insurance policy coverage.

1.  I certify that all information provided as part of this application is complete and accurate.
   
2. I understand this application must be completed on a semester basis in order to have my SJCC insurance waived
3. I understand that if my insurance coverage for which my approval is granted terminates for any reason, it is my waiver responsibility to notify the International Student Program at SJCC.
4. I understand that upon receiving waiver approval, I am responsible for all costs related to the purchase of non- SJCC insurance and any medical expenses not covered by the policy I selected.