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Health Insurance - Enrollment Form

You are about to purchase UScampus Group Health & Accident Insurance Plans

Please complete the form in English only. Click on "Continue" or "Submit" for the next step.

Step 1

Choose Your Plan *
Personal Information
Visa Type *	F1 J1 B1 M1
First Name *
Middle Name
Last Name *
Date of Birth *	MMDDYY
Gender	Male Female
Home Country Contact * (Country before arrive in U.S. is required field)	Name
	Relationship
	Phone Number

School Attending in USA
School Name *
Major
School Location * (City/State)
How Did You Hear about Us?
	Association of Graduate Student from Taiwan Chinese Culture Club Chinese Student Association R.O.C. Student Association Taiwanese Graduate Student Association Taiwanese Student Association Taiwanese Studies Society AIEF Web Site UScampus Web Site Friend Other
Mailing Address in the US
This is the address where your insurance card and information package will be sent to by mail. If you do not have the address available currently, AIEF will hold your package for you in its office. Please contact AIEF upon your arrival in the US by telephone to 714-985-1995, or e-mail to info@aief-usa.org or fax to 714-985-1996 to the attention of "Student Insurance".
Street Address
City
State
Postal / Zip Code
Phone Number
Fax Number
Email Address *
Emergency contact Name
Emergency contact Phone