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If I ask you to give acertificate in the following format, will you able to give it.
J-1 Exchange Visitor: ____________________________________________________________ ______________
print full name
Check if form is for J-2(s) who arrived/will arrive separately from the J-1
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This section must be completed by the health insurance provider??s authorized agent/employee
The U.S. government requires all J-1 Exchange Visitor Program participants and their J-2 dependents to maintain minimum health insurance coverage for the duration of their programs in the U.S. Sponsoring institutions are required to ensure that J-1 participants and their J-2 dependents are complying with the requirements (22 C.F.R. ?? 62.14). If there are any questions about this form, please contact the University of Hawaii Office of Faculty and Scholar Immigration Services.
Name(s) of insured individual(s):
____________________________________________ _____________________________________________
print full name print full name
____________________________________________ _____________________________________________
print full name print full name
____________________________________________ _____________________________________________
print full name print full name
Insurance provider: ____________________________________________________________ ________________
Policy/Plan type: _____________________________________________ Dates: ____________ to ____________
mm/dd/yyyy mm/dd/yyyy
The plan/policy must meet the following minimum coverage requirements (all amounts are in USD):
?E Provide medical benefits of at least $50,000 per accident or illness
?E Provide repatriation coverage of at least $7,500
?E Provide medical evacuation coverage to home country of at least $10,000
?E Maximum deductible of $500 per accident or illness
?E May require a waiting period for pre-existing conditions which is reasonable under current industry standards
?E May include a provision for co-insurance which requires the exchange visitor to pay up to 25% of the covered benefits per accident or illness
?E Does not unreasonably exclude coverage for perils inherent to the activities of the exchange program in which the exchange visitor participates
?E Coverage is guaranteed through at least one of the following means:
?? Insurance policy is underwritten by a health insurance company rated:
"A-" or above by A.M. Best or
"A-i" or above by Insurance Solvency International (ISI) or
"A-" or above by Standard & Poor??s Claims Paying Ability or
"B+" or above by Weiss Research, Inc. OR
?? Policy is backed by the full faith and credit of the government of the J-1??s home country OR
?? Policy is part of a health benefits program offered on a group basis to employees or enrolled students by a designated sponsor OR
?? Policy is offered through or underwritten by a federally qualified Health Maintenance Organization or eligible Competitive Medical Plan as determined by the U.S. Dept. of Health & Human Services.
The minimum coverage requirements stated above are provided by this policy/plan. I am qualified to make this determination as an authorized agent/employee of the above insurance provider.
J-1 Exchange Visitor: ____________________________________________________________ ______________
print full name
Check if form is for J-2(s) who arrived/will arrive separately from the J-1
----------------------------------------------------------------------------------------------------------------------------------------------
This section must be completed by the health insurance provider??s authorized agent/employee
The U.S. government requires all J-1 Exchange Visitor Program participants and their J-2 dependents to maintain minimum health insurance coverage for the duration of their programs in the U.S. Sponsoring institutions are required to ensure that J-1 participants and their J-2 dependents are complying with the requirements (22 C.F.R. ?? 62.14). If there are any questions about this form, please contact the University of Hawaii Office of Faculty and Scholar Immigration Services.
Name(s) of insured individual(s):
____________________________________________ _____________________________________________
print full name print full name
____________________________________________ _____________________________________________
print full name print full name
____________________________________________ _____________________________________________
print full name print full name
Insurance provider: ____________________________________________________________ ________________
Policy/Plan type: _____________________________________________ Dates: ____________ to ____________
mm/dd/yyyy mm/dd/yyyy
The plan/policy must meet the following minimum coverage requirements (all amounts are in USD):
?E Provide medical benefits of at least $50,000 per accident or illness
?E Provide repatriation coverage of at least $7,500
?E Provide medical evacuation coverage to home country of at least $10,000
?E Maximum deductible of $500 per accident or illness
?E May require a waiting period for pre-existing conditions which is reasonable under current industry standards
?E May include a provision for co-insurance which requires the exchange visitor to pay up to 25% of the covered benefits per accident or illness
?E Does not unreasonably exclude coverage for perils inherent to the activities of the exchange program in which the exchange visitor participates
?E Coverage is guaranteed through at least one of the following means:
?? Insurance policy is underwritten by a health insurance company rated:
"A-" or above by A.M. Best or
"A-i" or above by Insurance Solvency International (ISI) or
"A-" or above by Standard & Poor??s Claims Paying Ability or
"B+" or above by Weiss Research, Inc. OR
?? Policy is backed by the full faith and credit of the government of the J-1??s home country OR
?? Policy is part of a health benefits program offered on a group basis to employees or enrolled students by a designated sponsor OR
?? Policy is offered through or underwritten by a federally qualified Health Maintenance Organization or eligible Competitive Medical Plan as determined by the U.S. Dept. of Health & Human Services.
The minimum coverage requirements stated above are provided by this policy/plan. I am qualified to make this determination as an authorized agent/employee of the above insurance provider.
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