International Student/scholar Insurance Verification Form (J Visa) Template printable pdf download

INTERNATIONAL STUDENT/SCHOLAR INSURANCE VERIFICATION FORM (J visa)

UNIVERSITY SYSTEM OF GEORGIA (USG) BOARD OF REGENTS

(to be completed by students/scholars who do not intend to use the USG-approved insurance policy)

STUDENT / SCHOLAR NAME _______________________________________________________

U.S. STREET ADDRESS ___________________________________________________________

CITY_______________________________ STATE ___________ ZIP ____________________

I am participating in an exchange program at __________________________________________

from ____________ to __________.

I hereby authorize my insurance company to release the following information to the USG Office of

International Education:

Signature __________________________________________ Date______________________

This portion of the form must be completed by an insurance representative or insuring sponsor.

INSURANCE CO. NAME _____________________________________________________________

POLICY NAME _______________________________________________________

POLICY #____________________________________ EXPIRATION DATE _________________

U.S. ADDRESS ____________________________________________________________________

U.S. PHONE______________________ FAX___________________ EMAIL____________________

Please respond to the following based on the insured’s policy coverage:

yes

This policy provides coverage for the above student/scholar’s period of stay in the

United States.

This policy covers the student/scholar named above for medical benefits of at least

$50,000 USD per accident/illness incurred outside the student's home country.

A deductible no greater than $500 per accident or illness.

This policy includes a provision for co-insurance under the terms of which the

exchange visitor may be required to pay up to 25% of the covered benefits per accident or illness.

Coverage for repatriation of remains is equal to or greater than $7500 USD. Medical

evacuation coverage to the visitor’s home country is equal to or greater than $10,000 USD.

The insurance is acceptable in all licensed medical facilities. There are no restrictions

to the type of medical facility the insured may use. If conditions apply, please attach an explanation.

The policy meets requirements set forth by the Department of State Bureau of

Educational and Cultural Affairs for those on a J visa, including a reasonable waiting period for pre-

existing conditions and underwriters with an A.M. Best rating of A- or above, an Insurance Solvency

International, Ltd. (ISI) rating of A-i or above, a Standard & Poor's Claims-paying Ability rating of A-

or above, or a Weiss Research, Inc. rating of B+ or above.

Other than psychotherapy and dental treatment, are there any other internal plan

limitations? (The policy shall not unreasonably exclude coverage for perils inherent to the activities

of the exchange program in which the exchange visitor participates.) If yes, please list.

The undersigned certifies that all information is true, and that failure to provide correct information will

result in the cancellation of the student/scholar's participation in the program.

Signature of Sponsor or Insurance Representative: ________________________________________

Date: _______________________

*Please mail/fax directly to the University System of Georgia Office of International Education:

270 Washington St, SW, Suite 6014, Atlanta, GA 30334 USA (Fax: 404-651-2976)

International Student/scholar Insurance Verification Form (J Visa) Template