Professional Documents
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2500 North River Road | Manchester, NH 03106-1045 | Phone: 603.645.9676| Fax: 603.645.9603
SNHU
Please continue my enrollment in the CISI international student insurance offered through SNHU during my Optional Practical Training or Academic Training. I request coverage for the following period (minimum 3 months): Starting month/year:____________________ month/year:____________________ Ending
I acknowledge: CISI insurance will automatically expire if I do not request an extension of coverage prior to the end of current coverage. Coverage must be continuous and may not be restarted if I make this request after my CISI insurance expires. Payment for the insurance coverage is due immediately upon signing up and will be billed at the rate charged to students during the covered period. If I am covered by another insurer (such as through work) or if I depart the US prior to my requested ending month of coverage, then I may request a cancellation of any future full months that remain.
If I wish to continue or cancel coverage, I will contact: Elizabeth Collins, SNHU One Stop Office located in Exeter Hall or e.collins1@snhu.edu.
The importance of health insurance has been explained to me by International Student Services at the time of my application for OPT or AT. However, at this time, I choose to decline additional insurance through CISI and understand that I may not restart my CISI student policy at a later date if I do not elect coverage before my current CISI policy expires on the last day of my final month of course registration. _________________________________ ____________________________ Signature of student
Date
**************************************************************** ************** For ISS office use only: Scanned and e-mailed to One Stop Office on _____________ by __________________________ Revised 5/23/2012