International Student and Scholar Services

Insurance Adjustment Form

Please fill out the following response form
Date:11/07/2009* Required Fields
* B Number
* Last Name
* First Name
* Email Address
* Date of Birth mm-dd-yyyy
* Visa Type
* Funding /Adjustment Type
Reason for Insurance Adjustment/Waiver
Other Comments

If you experience any difficulties with this form, please contact International Student & Scholar Services.
Email: isss@binghamton.edu   Phone: 1-607-777-2510