Easy Steps to Get F1-OPT Insurance

Student Personal Information

Name

Email Id

Phone Number

Phone

Gender

Date of Birth

Your University

Is this Whatsapp number?

YesNo

Travel Information

Currently in India?

Travel Date

Coverage Start Date

Coverage End Date

Coverage Period

Other Information

Student's Pan Number

Sponsor Name

Emergency Contact Number

Phone

Alternate Email Id

Mother’s Name

Student's Passport Number

Nominee's Name

Nominee Relation

Nominee DOB

Address In India

Do you have a US address?

YesNo

Health Declaration

I have left India as on , and I request you to issue me a policy effective as soon as possible, since post my travel from India there have been no contingencies/medical events & emergencies reported by me till date. Also I do not anticipate any medical situation in the policy period from to which can lead in claim and hereby declare that I am in a sound physical and mental health at the time of the purchase of this policy.

The reason, I could not purchase the insurance before traveling as I was busy with my travel preparations and exams.

Name:

Date: 08-10-2024

Nominee Details

Name:

DOB:

Relation:

Let’s connect with
Phone or Email

+91 96508 36644

info@studentcover.in

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