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BCBS Global Insurance Application for STUDENTS

Blue Cross Blue Shield Global Insurance Application STUDENTS

"*" indicates required fields

Blue Cross Blue Shield Global is currently the University’s provider for insurance for travel outside the US. Coverage is mandatory and 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 – this coverage is for a single trip only.
  • * Payment may be made by check or charged to your student account.
  • * 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 GeoBlue 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*
Individual Travel*
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 and I authorize GPS to charge my student account for the premium for this trip (unless I have paid by check).
Today's Date*

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