Students with an F-1/J-1 visa who maintain other insurance coverage and wish to waive the NYU sponsored health insurance plan need to complete and sign the entire Student Acknowledgment and Insurance Carrier Certification Form (Waiver Application) before submitting it to the NYU Student Health Insurance Office.

This must be completed for each new academic year before the deadline.

  • Fall Deadline: September 30
  • Spring Deadline: February 10
  • Summer Deadline: June 5

Instructions

Download the Student Acknowledgement and Insurance Carrier Certification Form (PDF 499KB)

Section A – Top Portion of the Form
[STUDENT TO COMPLETE]

  1. Student is to complete all the areas that are highlighted in yellow and sign and date the form.
  2. Read the statement of acknowledgement carefully. The statement indicates that while you are enrolled at NYU, it is your responsibility to maintain health insurance coverage for yourself and that your plan must meet NYU’s requirements. It is also your responsibility to update your insurance coverage if the NYU requirements change, and to submit this form each time you renew your policy or change insurance carriers or plans.

Section B – Bottom Portion of the Form
[Insurance Company Representative to Complete]

  1. Your insurance company representative must complete all the areas that are highlighted in yellow, sign and date the form.
    IMPORTANT    : Your insurance company representative must initial each line that meets the minimum coverage requirements
  2. NYU Minimum Coverage Requirements
    1. While enrolled at NYU, you are required to have health insurance
    2. Health insurance coverage must be UNLIMITED per accident/illness.
      • Your plan must provide medical benefits (doctor visits, hospital, surgery, laboratory tests, x-rays, etc.) for each accident or illness.
    3. Inpatient/Outpatient medical coverage (including mental health, substance abuse and alcohol related illness or injury) in the New York City area.
      • Your plan must pay for covered medical expenses (including mental health, substance abuse and alcohol related illness or injury) for both inpatient (stay at an inpatient facility/hospital) and outpatient (doctor’s office, outpatient department of a hospital or ambulatory surgery center) services.
    4. Repatriation coverage must be at least $25,000 USD.
      • Your plan must provide at least $25,000 USD to send your body/remains back to your home country.
    5. Medical evacuation coverage to home country must be at least $50,000 USD.
      • Your plan must provide up to $50,000 USD for your medical evacuation to return home.
    6. No more than $1,500 USD deductible per policy year.
    7. No waiting period for pre-existing conditions.
      • Your plan cannot exclude coverage for any pre-existing conditions.
    8. Headquartered and operating in the US with a US claims address and telephone number.

Where to Submit this Form

This completed form may be e-mailed to health.insuranceattestation@nyu.edu

NYU Student Health Insurance
726 Broadway, Suite 346
New York, NY 10003
Phone: 212-443-1020
Email: health.insuranceattestation@nyu.edu