Insurance Payment Report


There are 10 questions in this survey.

Insurance Payment Report

Student ID
Name
Program
Dual Degree
Student Exchange
Summer Program
Independent Study Abroad
Country/Region
Host University
Departure Year (2018/2019/2020/2021 etc)

Departure Semester
Spring Semester
Fall Semester
Program Period (Example: March 18-31, 2019)
One year
One semester
Other: 
Insurance Plan
Plan S
Plan A
Plan B
Extension

Please upload the payment report (e.g. receipt).