Description of Coverage
In order for your insurance coverage to be approved, it must meet the minimum requirements as stated below.
>Deductible not to exceed $500 per incident or illness
>Medical and Accident Coverage: $100,000 per illness/accident
>Repatriation of Remains: $ 25,000 per illness/accident
>Expenses associated with the medical evacuation of exchange visitor to his/her home country in the amount of $25,000
An insurance company which meets the following rating standards as required by the U.S.government must underwrite any insurance policy secured to fulfill the above requirement:
>Have an A.M. Best rating of “A¥” or above or
>A McGraw Hill Financial/Standard & Poor’s Claims-paying Ability rating of “A¥” or above, or
>Weiss Research, Inc. rating of “B+ or above, or
>A Fitch Ratings, Inc. rating of “A¥” or above;, or
>A Moody’s Investor Services rating of “A3” or above
>Backed by the full faith and credit of the government of the exchange visitor’s home country
This form must be signed and notarized by a representative of your insurance company. You must also submit a copy of your insurance certificate stating your policy coverage and a copy of your payment receipt stating that your insurance is paid in full prior to your departure to the U.S.
Name of Insured
Company Issuing Insurance
Telephone Number Policy Number
U.S. Claims Office Address
Effective Dates: From To
(*Dates must cover your entire stay the U.S.including your 30 day grace period)
Health Insurance Verification Form
Please complete only if the agency in your home country (not IEE) is providing insurance.
Applicants please note only an authorized representative of your insurance company may submit this form.
A false submittal is automatic grounds for program termination, with no refund.
We certify that the above named person has obtained the coverage described above and that the actual coverage as detailed in the original policy at least matches or exceed the limits stated on this form.
By submitting this form, I acknowledge I am an authorized representative of the insurance company stated in this document.
A receipt showing proof of purchase for the coverage period must accompany this form
Note: All policies are required to cover the exchange visitor during the 30 day grace period upon completing the J-1 program.
Name of Insurance Representative
Email address of representative
Phone Number of Representative