Get Health Affidavit Form

Affidavit of Health Insurance Instructions and Sample Form The San Francisco Italian Consulate requires this form to verify compliance with health insurance requirements. All EAP students receive the mandatory EAP health/medical/travel insurance while studying abroad this insurance meets Italian standards. ALL STUDENTS Complete the top section of the Affidavit of Health Insurance Select option B as an EAP student you currently have a policy that complies with the Italian requirement previously mentioned an insurance policy without any sort of deductions restrictions or limitations. Sign the completed Affidavit of Health Insurance in front of a notary public Use the sample form below to help you complete the form SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE AFFIDAVIT FOR HEALTH INSURANCE COVERAGE I Write your full name as it appears on your passport first name middle name last name born in town/State Write the city and state you were born in on day-month-year Write date of birth in the manner indicated residing at permanent address Write your permanent address Phone number Area code Tel. Write in your permanent area code and phone number BEING FIRST DULY SWORN ON OATH DEPOSE AND SAY That within eight days of my arrival in Italy I will report to the Italian QUESTURA local Police Office for the issuance of my PERMESSO DI SOGGIORNO residence permit as requested by the Italian Government of all foreigners residing in Italy for an extended period of time That prior to appearing at the Questura I will have to purchase one of the following medical and hospitalization programs a Insurance policy with I. N.A. ASSITALIA Via del Tritone 181 Rome Bank account n. 7127003 which can be purchased at any Post Office upon arrival in Italy or with any other Italian insurance company of my choice OR X b Insurance policy with any other private health insurance company that will cover me for the medical/hospitalization bills in line with the Italian Government standards. All EAP students receive the mandatory EAP health/medical/travel insurance while studying abroad this insurance meets Italian standards. N*A. ASSITALIA Via del Tritone 181 Rome Bank account n* 7127003 which can be purchased at any Post Office upon arrival in Italy or with any other Italian insurance company of my choice OR X b Insurance policy with any other private health insurance company that will cover me for the medical/hospitalization bills in line with the Italian Government standards. That the above mentioned coverage will be for my entire stay in Italy and will be granted without any sort of limitation and deduction* Place and date Write date in front of the notary public Sign in front of the notary public Signature of the student OFFICIAL NOTARIZATION AND SEAL have the notary sign and stamp or seal the document once you ve signed it State of County of Subscribed and sworn to or affirmed before me this day of 20 by. N*A. ASSITALIA Via del Tritone 181 Rome Bank account n* 7127003 which can be purchased at any Post Office upon arrival in Italy or with any other Italian insurance company of my choice OR X b Insurance policy with any other private health insurance company that will cover me for the medical/hospitalization bills in line with the Italian Government standards. That the above mentioned coverage will be for my entire stay in Italy and will be granted without any sort of limitation and deduction* Place and date Write date in front of the notary public Sign in front of the notary public Signature of the student OFFICIAL NOTARIZATION AND SEAL have the notary sign and stamp or seal the document once you ve signed it State of County of Subscribed and sworn to or affirmed before me this day of 20 by.