Proof of Insurance Coverage

When filling out the form below, please make sure you include an insurance card or confirmation of enrolled dates. The insurance must meet the minimum requirements laid out below. The minimum requirements must be clearly stated in the insurance policy that you provide. If the insurance policy does not clearly state the categories below and the amounts covered, then the insurance company can issue a letter on letterhead stating the requirements below are met by the policy.

Minimum Alternate Insurance Requirements:
$500,000+ per injury or illness
$50,000+ medical evacuation
$25,000+ repatriation
Alternate insurance must have a United States based contact.

If you are a J visa holder you can learn more about your alternate insurance requirements here.

In accordance with policy 502.6 of UA Little Rock, it is mandatory for all F-1 and J-1 international students to obtain health and accident insurance and to ensure continuous coverage throughout the year. Students wishing to submit alternative insurance coverage must do so by the first day of classes each semester.

Proof of Insurance

Federal law (22 CRF 62.14) mandates J visa holders to maintain appropriate health insurance coverage during the duration of their stay in the US. To maintain active J status, students must find appropriate insurance coverage and provide proof of insurance coverage to the Office of International Student Services prior to the first day of class each semester.

Student's Name(Required)

First Last

Student ID Number(Required)

Student's Email(Required)

Enter Email Confirm Email

Reason for Alternative Coverage(Required)

Number of J-2 Dependents(Required)

List Name, Gender, and Date of Birth of Each J-2 Dependent(Required)

I understand that in order to be eligible for a waiver from the institutional insurance plan, I must enroll in an ACA compliant plan.(Required)

I understand.

I understand all J-2 dependents must maintain appropriate health insurance coverage throughout the entire duration of their J program.(Required)

I understand.

I understand the insurance coverage must include medical benefits of at least $500,000 for F visa holders and $100,000 for J visa holders per accident or illness.(Required)

I understand.

I understand the insurance coverage must include a minimum of $25,000 in repatriation of remains.(Required)

I understand.

I understand the insurance coverage must include a minimum of $50,000 in medical evacuation.(Required)

I understand.

I understand the insurance coverage must not have a deductible exceeding $500 per accident or illness.(Required)

I understand.

I understand failure to demonstrate and maintain federally compliant coverage will result in loss of immigration status.(Required)

I understand.

Proof of insurance coverage, such as insurance ID card.(Required)

Documentation must include dependent's name and the period of coverage.

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 1 MB.

Insurance policy coverage including summary of benefits or policy brochure.(Required)

Documentation must be in English and meet the federal requirements for J exchange visitors.

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 1 MB.

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