iNext Insurance Enrollment Form

 iNext is Berry's contracted health and travel insurance plan required for study abroad students, faculty, and staff.  Please pay close attention to detail.

 

                         Date of Birth:         

Last Name:      First name: 

Home Address:       City/State:       Zip: 
    
 Email:        Phone:        

 2nd Phone: 
   
Date of departure from your home: 
     This will be your insurance effective date (coverage begins on this day)

Date of arrival back at home:         
      This will be your insurance end date (coverage expires at end of this day)

 Emergency Contact Form

Please provide a person we may contact in the event of an accident, illness, or other emergency situation.

 

Name:        Relationship to you:   

 
       Phone (day):     (night):     (cell):   

Address:     Email: