About Our Office MissionOISS StaffOffice Hours and LocationPlace a Request Key Links AdmissionsJ-1 Exchange VisitorsImmigration / VisasEmploymentHealth InsuranceCommunity Immigration F-1 and J-1 Immigration BasicsImmigration DocumentsVisa ApplicationDependentsSEVIS RegistrationDriver's LicenseInternational TravelGuide for Final Semester Admission Requirements Online ApplicationAcademic TranscriptsEnglish RequirementsImmigration VerificationDemonstration of Financial Support J-1 Exchange Visitors Exchange VisitorsVisiting Research Scholar & FacultyRequirements Per CategoryExchange Visitor ProcessingJ-2 DependentsTwo-Year Home Residency RequirementHealth Insurance RequirementsJ Exchange Visitor Welcome PacketVisiting Scholar Exit Interview Employment Employment OverviewOn-Campus EmploymentCurricular Practical Training (CPT)Optional Practical Training (OPT)Academic TrainingSocial Security Number NameThis field is for validation purposes and should be left unchanged.Name(Required) First Last UALR ID Number(Required)Email Address(Required) Enter Email Confirm Email US Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Immigration Status(Required) F-1 J-1 Other Reason for Insurance Enrollment — Choose an Option from the List(Required)Early enrollmentEmergencyOPTVisiting ScholarLost Governmental CoverageWe 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) MM slash DD slash YYYY Date of Loss of Coverage(Required) MM slash DD slash YYYY When did your previous insurance end?Program Start Date on DS-2019(Required) MM slash DD slash YYYY Statements of UnderstandingI 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, or sooner if the Emergency option is selected above.(Required) I agree. Captcha
