GeoBlue Worldwide Health Insurance Enrollment Form

Fields with asterisks (*) are required.

Copy of GeoBlue Worldwide Health Insurance Payment Receipt *

First name *

Last name *

Email *

Date of Birth *

Gender *

Male

Female

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Phone Number *

Program Information

College/School Affiliation *

Eugene Applebaum College of Pharmacy and Health Sciences

Wayne Law

Wayne State University College of Nursing

Wayne State University School of Medicine

Wayne State University College of Engineering

Other

Program Name *

Host Country *

Host City *

Departure Date *

Return Date *

Country of Issued Passport *

Payment

I wish to enroll for insurance under the terms of Wayne State University's master insurance policy with GeoBlue Worldwide Health Insurance for Higher Education.

Type of Insurance *

The stated premium of $2.25 per day is valid until 12/31/2022. I certify that I meet eligibility described in the attached brochure. I acknowledge that benefits will not apply to treatment arising from pre-existing medical conditions. Payments must be made via studyabroad.wayne.edu website through the online payment system. Total premium for Full Term coverage must be paid in U.S. dollars at the time your application for coverage is submitted. (CASH/CHECKS ARE NOT ACCEPTED)

Number of Days Please be sure to include the day of your departure and your return date in the total number of days. *

Grand Total *

In regards to payment *

I understand.

I do not understand.