Insurance Enrollment

All international students are enrolled in health insurance during the first 30 days of the semester. Please submit this form if you have an emergency and require early enrollment, if you are adding a dependent in a life-changing circumstance, or if you would like to include dependents on your insurance enrollment. All requests for enrollment will be reviewed by an ISS staff member and submitted to LewerMark. Please allow at least 2 business days for enrollment.

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 2 business days.(Required)

I agree.

Name

This field is for validation purposes and should be left unchanged.

Insurance Enrollment

Statements of Understanding

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