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Insurance Explained
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Liaison Student Insurance
Please fix the following errors:
Applicant Information
US Destination
US Destination
Choose One:
Yes
No
If your trip includes the US or any US territory, select Yes
Policy Level
Choose One:
Economy
Choice
Elite
View the
plan benefits
for more information on the different policy levels
Date of Birth
Applicant Date of Birth
Coverage Dates
Start Date
Coverage Start Date
Date that coverage should begin. This date cannot be more than 6 months from today.
End Date
Coverage End Date
This date cannot be more than 12 months from the date coverage begins.
Yes, I need dependent coverage.
Coverage Options
Hazardous Activities
Choose One:
Declined
Selected
Dependent 1
Dependent 1
Only specify the date of birth if this person is to be covered.
Dependent 1
Dependent 1
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Dependent 2
Dependent 2
Only specify the date of birth if this person is to be covered.
Dependent 2
Dependent 2
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Dependent 3
Dependent 3
Only specify the date of birth if this person is to be covered.
Dependent 3
Dependent 3
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Dependent 4
Dependent 4
Only specify the date of birth if this person is to be covered.
Dependent 4
Dependent 4
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Dependent 5
Dependent 5
Only specify the date of birth if this person is to be covered.
Dependent 5
Dependent 5
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Dependent 6
Dependent 6
Only specify the date of birth if this person is to be covered.
Dependent 6
Dependent 6
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Dependent 7
Dependent 7
Only specify the date of birth if this person is to be covered.
Dependent 7
Dependent 7
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Dependent 8
Dependent 8
Only specify the date of birth if this person is to be covered.
Dependent 8
Dependent 8
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Dependent 9
Dependent 9
Only specify the date of birth if this person is to be covered.
Dependent 9
Dependent 9
Only specify the date of birth if this person is to be covered.
Choose One:
Spouse
Child
Add more dependents
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