J-1 Exchange Visitor: Statement of Compliance with New Health Insurance Regulations

--- Statement of Compliance with New Health Regulations ---

PLEASE NOTE THAT, as of May 15, 2015, the Department Of State (DOS) will enact the following requirements, as per regulation (22CFR 62.14(b)).

All J-1 exchange visitors and their J-2 dependents are required by federal regulation to procure medical insurance for the entire duration of their J-1 program in the United States. Failure to maintain required health insurance coverage is a violation of J-1 status and may result in loss of valid immigration status and termination from the Exchange Visitor Program. Relevant DOS regulations are published in the Code of Federal Regulations [22 CFR 62.14]. J-1 Exchange Visitors and J-2 dependents must obtain a health insurance policy that meets or exceeds these benefits:

1. Medical benefits of at least $100,000 per accident or illness;

2. In case of death, repatriation of remains in the amount of $25,000;

3. Expenses in the amount of $50,000 associated with the medical evacuation of the J Exchange Visitor to his or her home country;

4. A deductible amount not to exceed $500 per accident or illness

Purpose of this form: Required of all J-1 Scholars for whom Northeastern has issued J-2 documents for spouses and/or dependents. Background: This document is based on the Department of State (DOS) regulation (22 CFR Section 62.13(a)(4)), effective 1/5/2015, requiring tracking and reporting of early departures of J-2 accompanying spouses and dependents. The DOS has stated that it is incumbent upon sponsors to implement programmatic rules to satisfy the above reporting requirement, making the reporting requirement a condition of bringing an accompanying spouse and dependent/s. Therefore, each J-1 Scholar bringing his/her spouse or dependent is required, as of 1/5/2015, to complete and submit this e-form.

Statement of Compliance

* I have read the above information on the J-1 health insurance requirements and I pledge to obtain and maintain insurance, meeting all these requirements, for myself, and for any accompanying dependents, throughout the entire duration of my J program. I also attest that I have read and understand the following DOS regulation: “Exchange Visitors who willfully fail to maintain the insurance coverage set forth above (and below as of 5/15/2015) while a participant in an exchange visitor program or who make material misrepresentations to the sponsor concerning such coverage will be deemed to be in violation of these regulations and will be subject to termination as an exchange visitor. Sponsors must terminate an exchange visitor’s participation in their program if the sponsor determines that the exchange visitor or any accompanying spouse or dependent willfully fails to remain in compliance.”ISSI is required by the DOS to confirm that the J-1 Exchange Visitor has fulfilled his/her obligation to purchase the requisite insurance prior to providing any J-1 benefit, including but not limited to travel signatures, extensions and transfers. Therefore, ISSI reserves the right to request both policy name and number at any time. By submission of this form, I attest that I will be able to provide both insurance policy name and number to the ISSI upon request.

J-2 Reporting Requirement

* Do you have a J-2 dependent (e.g. spouse, child)?

calendar
* When will Dependent #1 leave the US?
calendar

calendar
* When will Dependent #2 leave the US?
calendar

calendar
* When will Dependent #3 leave the US?
calendar

calendar
* When will Dependent #4 leave the US?
calendar
* Indicates Response Required