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 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(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.(Required) I agree. CaptchaCommentsThis field is for validation purposes and should be left unchanged.
