Summary: Student Health Benefit Plan
2011-2012 International Student
Waiver Request Form
Please submit to: Office of Student Health Benefits, 410 Church Street S.E., N323, Minneapolis, MN 55455. Fax: (612) 626-5183 or 1-800-624-9881.
Please keep a copy of this form for your records. For more information, visit the Office of Student Health Benefits website at www.shb.umn.edu.
International students are required to enroll in the University-sponsored Student Health Benefit plan unless they are already enrolled in a United
States-based employer-sponsored group health plan or the University-sponsored Graduate Assistant Health Plan.
To request a waiver from the University-sponsored Student Health Benefit Plan, submit this form to the Office of Student Health Benefits along
with proof of coverage. All eligible students must complete the waiver request process by the Twin Cities campus class registration deadline (this
deadline can be found on the One Stop website). Please keep a copy of this form for your records.
A. Student Information
Name (Last, First, Middle Initial) (Please Print) Date of Birth (mm/dd/yyyy) Gender U of M ID Number
Street Address, City, State, Zip Code Daytime Phone Email Address
Campus (check one): ___ Crookston ___ Duluth ___ Morris ___ Rochester ___ Twin Cities
B. Health Plan Information--which type of health plan do you have?
___ A United States-based employer-sponsored group health plan--Students who select this options must also submit proof of coverage such as