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					                            Fall 2011        - University of Wyoming Scholar SEVIS Semester Update
All J-1 exchange visitors must complete this form EVERY semester. Fill in EVERY blank with current information.
           Please type and email to ISS at uwglobal@uwyo.edu by Friday, September 2, 2011 at 4:30pm.


Family Name:                                         First Name:                                       Middle Name:

SEVIS# N                                             UW I.D. W                                     SSN:
*SEVIS # is located on DS-2019 above bar code on the right

E-mail Address:                                                         Phone Number:

Current U.S. Address:

House#/Street/Apt#:                                          City:                            State:                 Zip:
Visa & I-94 Information:

Visa Number (in red on the visa):                                       Exp. Date:
I-94 Departure #:                                Last Port/City of Entry:                              Last Date of Entry:
                                                                                                                            (mm/dd/yyyy)

Please provide copies of your new visa, passport I-94 to ISS EACH time you re-enter the United States.


Name of Emergency Contact in home country:                                                       Relationship:
Phone Number:                                                                                    Do they speak English?         Yes        No
Explanation of the Federally Regulated Mandatory Health Insurance Requirement for J Exchange Visitors:
The Department of State (DOS) administers the J-1 Exchange Visitor Program. UW is designated by DOS as a program sponsor and
must follow its guidelines closely. As such, any Exchange Visitor visiting UW is required to have health insurance for themselves
and accompanying family members for the entire period of stay in the United States. The minimum coverage that is required by
U.S. Department of State and UW includes:
         a.)   Medical benefits of at least $50,000 per person, per accident or illness
         b.)   At least $7,500 for repatriation of remains
         c.)   $10,000 minimum for expenses associated with medical evacuation
         d.)   A policy secured to fulfill the insurance requirements shall not have a deductible that exceeds $500 per accident or illness,
               and must meet other standards specified in the regulations.
The regulations also state that "willful non-compliance to the regulation will result in termination of the exchange visitor's program".
As a sponsor of Exchange Visitor programs, the University of Wyoming requires that you indicate at least twice a year, by completing
this form, that you both understand the health insurance requirements and will comply with the regulations. All J-1 students must
purchase the UW International Student Health Insurance plan for themselves, or have approved comparable coverage. They may also
purchase the mandatory policy for their dependents or choose for them another policy of equal coverage. Other classifications of J-1
Exchange Visitors i.e., researchers, scholars, faculty, specialists, etc., may purchase the University's International Student Health
Insurance policy or choose another of equal coverage. In addition, by completing the information below, you are acknowledging that
UW can terminate your exchange visitor program if you willfully fail to enroll in, and maintain the prescribed minimum coverage for
yourself and any accompanying dependents. Failure to sign this memorandum will indicate non-compliance to the health insurance
regulation. A copy of this memo will be kept in your International Students and Scholars file until the conclusion of your exchange
visitor program.

By typing my initials here (           ), I confirm that I have medical insurance that meets the minimum federal requirements
for J exchange visitors. My health insurance is provided by                  (name of company)

What is the amount of your deductible per accident or illness? $        . Who provides your supplemental insurance
for medical evacuation & repatriation of remains?         (name of company)
If your spouse/dependents are living in the United States, please complete the following information:

J-1 Name:

Spouse Information:

Family Name:                       First Name:                           Middle Name:                 Visa Type:
Check one:      Male      Female     Date of Birth:         /        /       Last date of US entry:      /       /
Country of Citizenship:                                   (mo/day/yr)                                  (mo/day/yr)



Child Information:

Family Name:                       First Name:                           Middle Name:                 Visa Type:
Check one:      Male      Female     Date of Birth:         /        /       Last date of US entry:      /       /
Country of Citizenship:                                   (mo/day/yr)                                  (mo/day/yr)


Family Name:                       First Name:                           Middle Name:                 Visa Type:
Check one:      Male      Female     Date of Birth:         /        /       Last date of US entry:      /       /
Country of Citizenship:                                   (mo/day/yr)                                  (mo/day/yr)


Family Name:                       First Name:                           Middle Name:                 Visa Type:
Check one:      Male      Female     Date of Birth:         /        /       Last date of US entry:      /       /
Country of Citizenship:                                   (mo/day/yr)                                  (mo/day/yr)


Family Name:                       First Name:                           Middle Name:                 Visa Type:
Check one:      Male      Female     Date of Birth:         /        /       Last date of US entry:      /       /
Country of Citizenship:                                   (mo/day/yr)                                  (mo/day/yr)



                  PLEASE PROVIDE COPIES OF YOUR DEPENDENTS’ TRAVEL/IMMIGRATION DOCUMENTS
                         TO ISS UPON THEIR ARRIVAL OR RE-ENTRY TO THE UNITED STATES.


Federally Regulated Mandatory Health Insurance Requirement for J Exchange Visitors’ Dependents:

By typing my initials here (       ), I confirm that my dependents have medical insurance that meets the minimum
federal requirements for J exchange visitors.
Their health insurance is provided by            (name of company)

If their primary insurance is Great West, what is the amount of the deductible? $          . What company provides their
supplemental insurance for medical evacuation & repatriation of remains?

				
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