Insurance Enrollment

All international students are automatically registered for health insurance within the first 30 days of the semester. It is important to note that students starting their studies in the fall semester will have an insurance start date of August 1. In contrast, those beginning in the spring semester will have an effective date of January 1. If you encounter an emergency and need to enroll early, please fill out this form. All requests for enrollment will be reviewed by an ISS staff member and submitted to LewerMark. Please allow at least three business days for the enrollment process to be completed.

Name(Required)

First Last

UALR ID Number(Required)

Email Address(Required)

Enter Email Confirm Email

US Address(Required)

Street Address Address Line 2 City State ZIP Code

Immigration Status(Required)

F-1

J-1

Other

Reason for Insurance Enrollment(Required)

We can submit an early enrollment if needed, but please let us know if this is a medical emergency or if you need your card for a doctor's appointment.

Date of Graduation(Required)

Date of Loss of Coverage(Required)

When did your previous insurance end?

Program Start Date on DS-2019(Required)

Statements of Understanding

I verify that the information submitted in this form is true and accurate. I am submitting this form myself and not on behalf of another.(Required)

I agree.

I understand that my insurance eligiblility will be assessed by an international student advisor before I will be enrolled in LewerMark.(Required)

I agree.

I understand that as a J-1 scholar, I must also enroll J-2 dependents in health insurance to legally remain in the US. J-2 dependents are not enrolled along with the principle (J-1) in the institutionally approved plan.(Required)

I understand.

I agree to pay all charges associated with this insurance enrollment. Any changes made to my enrollment may be made to the upcoming semester.(Required)

I agree.

I understand that my request for enrollment will be reviewed by an ISS staff member and submitted to LewerMark, which may take up to 3 business days.(Required)

I agree.

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Insurance Enrollment

Statements of Understanding

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