Health Insurance Report Form

   Health Insurance Report Form


1. Student Information
Name*    Family Name
Country*
Student ID Number*
Passport Number*
Faculty*
Major / Field of Study*
Level of Study*  or Other...
Student Status*  or Other...
Mobile Phone*    Email
2. Emergency Contact Person
Name*    Family Name
Relationship to Student*
Mobile Phone*    Email
3. Health Insurance Information
Company Name*
Period of Insurance*

Issue Date* / /

Expiry Date* / /

Remarks

Attachment :

1. Copy or Photo of Health Insurance Contract or Health Insurance Card*
*jpeg only
    

2. Copy or Photo of Passport*
*jpeg only
    

3. Copy or Photo of Student ID Card*
*jpeg only
    

4. Copy or Photo of Other.
*jpeg only
    

5. Copy or Photo of Other.
*jpeg only
    


Health Insurance Report Form
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