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					                         International Visitors and Academic
                         Experiences Program

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     University of Puerto Rico
     Rio Piedras Campus
     Deanship of Academic Affairs
                                                   HEALTH INSURANCE CERTIFICATION

The United States Government, Department of State, Federal Code 22, Section 514 establishes as a condition to receive
a J-1 or J-2 visa that the participant must carry and maintain adequate health insurance coverage for him or her and for
his or her family members. Government regulations stipulate that if the participant fails to maintain health insurance, the
institution must terminate the program participant.

Therefore, as part of the requirements to participate in our Program we ask you to certify that you will comply with the
health insurance coverage.

      I.            FOR VISITORS THAT WILL NOT BRING ANY DEPENDENTS (SPOUSE, CHILDREN)

                    I certify that I will carry and maintain adequate health insurance as stated below:

                                    I have health insurance with the University of Puerto Rico.

                                    I have health insurance with a well-recognized company in USA or Puerto Rico.
                                    Identify and provide copy of the coverage:


                                    I have another type of health insurance (If you select this alternative, you accept that if a
                                    medical emergency occur to you, you will be responsible for the medical hospital
                                    expenses).
                                    Identify and provide copy of the coverage:




      II.           FOR VISITORS THAT WILL BRING DEPENDENTS (SPOUSE, CHILDREN)

                    I certify that I will carry and maintain adequate health insurance for me and my family as stated below.

                                    I have health insurance with the University of Puerto Rico and it covers my family.

                                    I have health insurance with a well-recognized company in USA or Puerto Rico and it covers
                                    my family.
                                    Identify and provide copy of the coverage:


                                    I have another type of health insurance that covers my family (If you select this alternative,
                                    you accept that if a medical emergency occur to you or your Dependents, you will be
                                    responsible for the medical hospital expenses).
                                    Identify and provide copy of the coverage:


I certify that I will carry or currently carry adequate health insurance. I also certify that I understand that my J-1 program
will be immediately terminated if I fail to maintain health insurance for my family members and myself.



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                      PO Box 23344, San Juan PR 00931-3344. Tel. (787) 764-0000, ext. 2304, 2928, 4931. Fax (787) 763-4265
                                               Equal Employment Opportunity Employer M/M/V/I

				
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posted:8/28/2011
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