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Application For Insurance Coverage

APPLICATION FOR INSURANCE COVERAGE
Administered by HCC Medical Insurance Services Group
Group Number: AT16G126000 & AT16G12700








DESCRIPTION OF COVERAGE
Insurance does not cover dental/optical
​              
                                           A.  Illness and accident coverage per incident:         $100,000.00 USD 
                                           B.  Emergency Medical Evacuation/Repatriation:      $ 50,000.00 USD
                                           C.  Return of Mortal Remains:                                    $ 25,000.00 USD

​  Insurance begins with the start date on your DS-2019 form and ends on the 
completion date on your DS-2019 form.                           

*The deductible is the amount paid out of your pocket per each incident.

Insurance deductibles options: $50.00 or $250.00 USD per incident or illness 





Please check the program that you are applying for:



















    By submitting this application, I verify that I wish to be covered by the insurance program designed for the J-1  Training/Intern/Work and Travel program administered by Seven Corners.


Family Name
Given Name
Middle Name
Insurance coverage during your 30 day grace period is not a mandatory requirement under the Department of State regulations; however, if you wish to be covered please indicate so below.  If you elect not to be covered during the grace period, you acknowledge that any injury or illness that may occur during your grace period will not be covered by your insurance policy.     
Work and Travel Program
6 month Intern/Training Program
12 month Intern/Training Program
18 month Training Program
I request a $50.00 deductible
I request a $250.00 deductible
I would like coverage during my 30 day grace periodI do not want coverage during my 30 day grace period