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Insurance - MANDATORY INSURANCE REQUIREMENT CERTIFICATION

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					 MANDATORY HEALTH INSURANCE REQUIREMENTOF THE EXCHANGE VISITOR PROGRAM


                                        Dashew Center for International Students and Scholars
                                                                   106 Bradley International Hall
                                                                                Campus 137907
                                                     Phone (310) 825-1681, Fax (310) 206-1612

22CFR62.14 of the United States Code of Federal Regulations governing Exchange Visitor Programs
requires that the exchange visitor obtain health, accident, medical evacuation and repatriation of
remains insurance. The insurance policies must cover the exchange visitor and all accompanying
dependents. The insurance must provide the follow ing coverage:

 *     medical benefits of at least $50,000 per accident or illness
 *     repatriation of remains in the amount of $7,500
 *     expenses associated with the medical evacuation of the exchange visitor to his or her home
       country in the amount of $10,000
 *     a deductible not to exceed $500 per accident or illness.

The insurance policy must be underw ritten by an insurance corporation having an A.M. Best rating of
" A-" or above, an Insurance solvency International, Ltd. (ISI) rating of " A-" or above, a Standard &
Poor' s Claims paying Ability of " A-" or above, a Weiss Research, Inc. rating of " B+ " or above, or
such other rating services as the Agency may from time to time specify. Insurance coverage backed
by the full faith and credit of the government of the exchange visitor' s home country shall be deemed
to meet this requirement.

Any exchange visitor w ho w illfully refuses to comply w ith this requirement shall be considered to be
in violation of his/her exchange visitor status. The program sponsor is obligated to inform the United
States Department of State of the exchange visitor' s noncompliance.

For further information and assistance, please contact the Dashew Center for International Students
and Scholars (DCISS) at the above address and telephone number.

                  M ANDATORY INSURANCE REQUIREM ENT CERTIFICATION

I certify that I have read and understand the information above concerning the US Department of
State requirement for exchange visitors to have insurance. I understand that it is my responsibility to
have insurance coverage at all times during my stay in the U.S. Not follow ing this mandatory
requirement can lead to the termination of my appointment at UCLA and my J Visa status.

____________________________________________           _____/_____/_____
Signature                                                      Date

____________________________________________ ________________________________________
Print Name                                                  Phone #

My dependents (if applicable) and I are in compliance; have obtained the appropriate insurance
coverage as indicated above, and w ill maintain the required insurance throughout my stay in the U.S.
as an Exchange Visitor.

____________________________________________           _____/_____/_____
Insurance Provider Name                                         Expiration Date

____________________________________________
Insurance Policy Number

Please Note: If you do not have the insurance information with you, please provide DCISS with the
completed form within 10 days after “check-in”. (Drop off in person or send by Fax (310) 206-1612)