Professional Documents
Culture Documents
Have a documented need for health insurance coverage for family member(s) and demonstrate
inadequate financial resources to pay a full health insurance premium.
The Awards Committee will only review completed applications. Completed applications MUST
include:
Application form (attached)
A copy of the student's current account balance from STUINFO
Bank statements for the past three months that show detailed financial transactions (i.e., savings,
checking, certificate of deposits, etc.)
A personal statement explaining clearly the circumstances which have led to your financial need.
Proof of monthly housing payment (either rent or mortgage payment)
Proof of any other monthly debt such as a car payment or credit card balance
Recent pay stubs from campus or other employment
Any other documents which might demonstrate your need
Application Deadline:
Completed applications and all supporting documents must be received by Friday, September 15, 2016.
Applications must be printed and submitted to OISS, Room 105 International Center.
Questions?
Please contact OISS:
International Center, Room 105
Phone: 517.353.1720 | Fax: 517.355.4657
Email: ihealth@msu.edu | Web site: www.oiss.msu.edu
First Name:
PID:
Date of Birth:
Local Address:
City:
State/Zip Code:
No
Email Address:
Please fill out the following information about each of the immediate family members for whom
you are applying to enroll in health insurance coverage:
Last Name:
First Name:
Date of Birth:
Child
Female
How were this persons health needs managed during the Spring 2016 term? (02/15/16 08/14/16)
No health coverage
Ingham Health Plan B
Blue Care Network Student Health
Other (please explain):
Last Name:
First Name:
Date of Birth:
Child
Female
How were this persons health needs managed during the Spring 2016 term? (02/15/16 8/14/16)
No health coverage
Ingham Health Plan B
Blue Care Network Student Health
Last Name:
First Name:
Date of Birth:
Child
Female
How were this persons health needs managed during the Spring 2016 term? (02/15/16 8/14/16)
No health coverage
Ingham Health Plan B
Blue Care Network Student Health
Other (please explain):
If needed, please attach duplicate pages to list all family members for whom you are applying.
ACKNOWLEDGEMENT:
I hereby acknowledge that the information submitted herein and in any supporting materials is true,
correct, and complete to the best of my knowledge.
Signature:
Date: __________________________