TM
Youth Exchange Insurance Reimbursement Request
For Outbound Students required to purchase host country’s insurance
The District 5950/5960 Youth Exchange Program will reimburse the cost of the basic insurance
policy required by the host country, in place of providing the CISI-Bolduc policy. Insurance
upgrades, if any, are the responsibility of the insured.
Please print legibly
Name of student:
__________________________________________
Country to which student is assigned:
__________________________________________
Date of departure to country (mo./day/yr.)
__________________________________________
Cost of insurance policy, expressed in US dollars, at time of purchase: (If purchase was with non US
currency, please provide third party document showing exchange rate around the time the insurance was
purchased (www.fxtop.com Historic Exchange Rates, and www.x-rates.com/cgi-bin/hlookup.cgi among others,
provide this information)
$_________________
Issue reimbursement check to:
Name
____________________________________________________________
Address
____________________________________________________________
____________________________________________________________
(Zip code)
Signature of student or parent/guardian:
__________________________________________
Signature of Rotary District 5950/5960
Country Officer, authorizing reimbursement: _________________________________________
Please attach receipt, or other proof of payment (e.g. copy of appropriate portion of credit card
statement) and third party report of exchange rate, if applicable, and send to:
North Star Rotary Youth Exchange Office
11251 Red Fox Drive
Fax: 763-550-0619
Maple Grove, MN 55369
E-mail: diane.confer@comcast.net