International Student Health Insurance

International Student Health Insurance

Lang Wellness Center 815-226-4083 healthcenter@rockford.edu
Please make sure you complet this form before you arrive at Rockford University.
Name*

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.
Birth Date*

MonthDayYear
Rockford University Email*
example@example.com
Are you a Rockford University Student Athlete?*

YesNo
Do you have adequate health insurance (including intercollegiate sports participation) to cover you during the 2024/25 academic year?*

YesNo
Do you have adequate health insurance to cover you during the 2024/25 academic year? Adequate health insurance plans include those provided by GoCampus and SACM.*

YesNo
Please upload a copy of your health insurance card.*

Cancelof
I understand that by signing below, I am stating that I am currently covered by a health insurance plan (copy of card uploaded above) and the plan has adequate coverage (including intercollegiate sports participation). If there is any change in coverage or expiration of coverage during the 2024/25 academic year, I agree to notify Lang Wellness Center immediately to update my health insurance.*

Clear
I understand that by signing below, I am stating that I am currently covered by a health insurance plan (copy of card uploaded above) and the plan has adequate coverage for the 2024/25 academic year. Adequate health insurance plans include those provided by GoCampus and SACM. If there is any change in coverage or expiration of coverage during the 2024/25 academic year, I agree to notify Lang Wellness Center immediately to update my health insurance.*

Clear
Please complete the information below to enroll in CareMed - our international student health insurance - Platinum Plan. Your Rockford University student account will be billed $149.98 per month for this health insurance coverage.

Please contact Lang Wellness at 815-226-4083 or healthcenter@rockford.edu with any questions.
Gender*
Home Country
Destination City*
Insurance Start Date*
month/day/year
Insurance End Date*
month/day/year
Signature*

Clear
Date*

MonthDayYear
Date
Please contact Lang Wellness Center/Rockford University at 815-226-4083 Monday - Friday to enroll in our international athletic health insurance.
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