International Student Insurance Drop Request

This form is for international students who are enrolled at Tacoma Community College but are not presently in the United States and wish to un-enroll in their international health insurance policy.

For students who wish to take a quarter off and un-enroll in health insurance, please use the Advising Request form instead: https://entry.tacomacc.edu/register/?id=5ac19e44-8870-4d07-81c2-e47d502f76bc

Contact Information

Last (Family) Name

First (Given) Name

Student ID #:

SEVIS ID # or Date of Birth

Gender

City of Birth

Country of Citizenship

TCC Email Address

For which term would you like to un-enroll in health insurance?

Where outside the U.S. are you currently living or where are you traveling to?

Departure Date

Return Date

Financial Responsibility

I understand that I will be financially responsible for any medical expenses incurred during the quarter in which my insurance is dropped.

Break in Coverage

I acknowledgment that upon my return to the U.S., I am subject to any pre-existing condition waiting periods under the policy.

**Please Note**

Do not make a tuition payment until you are notified by an advisor that the insurance charge is removed from your student account.

E-Signature (type your full name)