INTERNATIONAL FAMILY HEALTH INSURANCE AWARD

INFORMATION AND INSTRUCTIONS

The MSU Office for International Students and Scholars (OISS) is pleased to announce that we have
limited funding to continue the International Family Health Insurance Award Program (FHIAP) for Fall
2015. If selected, this award can help pay for up to 6 months of health insurance coverage for one or
more immediate family members. Coverage will be effective 8/15/2016 to 2/14/2017.
To qualify, applicants MUST meet the following criteria:

Have a documented need for health insurance coverage for family member(s) and demonstrate
inadequate financial resources to pay a full health insurance premium.

Be in good academic and immigration standing.

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

APPLICATION FORM FALL 2016

INTERNATIONAL FAMILY HEALTH INSURANCE AWARD PROGRAM (FHIAP)
STUDENT INFORMATION:
Last Name:

First Name:

PID:

Date of Birth:

Local Address:
City:
State/Zip Code:

Do you hold a Graduate Assistantship in Fall 2016?

Yes

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:

Gender (circle one): Male

Relationship to you: Spouse

Child

Female

Visa (circle one): F-2 J-2 US Citizen Other:______

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:

Gender (circle one): Male

Relationship to you: Spouse

Child

Female

Visa (circle one): F-2 J-2 US Citizen Other:______

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):

Last Name:

First Name:

Date of Birth:

Gender (circle one): Male

Relationship to you: Spouse

Child

Female

Visa (circle one): F-2 J-2 US Citizen Other:______

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: __________________________

Office for International Students and Scholars | Michigan State University

International Center, Room 105
Ph: 517.353.1720 | Fax: 517.355.4657
Email: ihealth@msu.edu
Web site: www.oiss.msu.edu