ITU Student Insurance-20150619

International Technological University
2711 North First Street, San Jose, CA 95134
Phone 888-488-4968
itu.edu

Apply Now for Health Insurance

THIS IS NOT THE WAIVER

Full Name *

First Name Last Name

Student ID *

Email Address *

example@example.com

Address (US Address Only) *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date of Birth *

Month Day Year

Gender: Male (M) or Female (F) *

M F

Are you a Domestic (DOM) or International (INT) Student? (Students on Visa are considered International) *

DOM INT

Academic Level *

Refund Policy:
In order to be eligible for a refund, you need to meet ALL of the following:

You are withdrawing from ITU within 30 days of the plan start date.
You have not used the insurance or filed claim(s).

All refunds require approval from JCB Insurance Services*. ITU will not process student insurance refund requests without authorization from JCB Insurance Services.

Refund Policy *

I Agree

By selecting "I agree" below, I agree to pay the student insurance premium. I hereby acknowledge that I have read and understood the refund policy regarding student insurance premium. If I am paying my student insurance premium using a third party credit card, I hereby acknowledge that I have relayed the terms and conditions to the third party card holder and have his/her consent in making this payment. I agree that if the third party card holder disputes the transaction at a later date, for any reason, I, as the applicant will be held fully liable for all fees and penalties incurred from the dispute of payment, including the original student insurance premium.

Payment Acknowledgement *

I Agree

*JCB Insurance Services is ITU's Insurance Broker