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BCBS Global Insurance Application Form for Faculty/Staff

Blue Cross Blue Shield Global Insurance Application FACULTY/STAFF

"*" indicates required fields

Faculty and Staff have the option of iNext or Blue Cross Blue Shield Global (formerly GeoBlue) as a provider for insurance for travel outside the US. Coverage is mandatory. If selecting Blue Cross Blue Shield Global, coverage includes accident and sickness as well as political security and natural disaster evacuation services. Full coverage information is available on our website. This policy is not a substitute for primary health insurance. You should contact the Center for Global Programs & Studies for further information and a rate quote – Blue Cross Blue Shield Global coverage is for a single trip only.
  • * Payment may be made by check or charged to your departmental budget.
  • * If enrolling a spouse or children, please complete separate applications for each.
Once the Center for Global Programs and Studies has processed your application, you will receive an email from Blue Cross Blue Shield Global asking you to login to their website to complete a login profile so that you will have full access to their online services.
Name*
Permanent Residence Address*
Date of Birth*
WFU Affiliation*
School*
MM slash DD slash YYYY
MM slash DD slash YYYY
For your records, a copy of this form will be sent to this email address.
Gender
Please type your First and Last Name. I understand that by typing my name in the signature box below, this constitutes a legal signature.
Today's Date*

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