Wufoo

Name * First Last
Date of Birth * MM / DD / YYYY
Gender *
Male Female
City of Birth *
Maximum Allowed: 30 characters. Currently Used: 0 characters.
Country of Birth
*
Maximum Allowed: 30 characters. Currently Used: 0 characters.
Country of Citizenship *
Country of Permanent Residence *
Email Address *
Phone Number ### - ### - ####
Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Education

A description of the section goes here.
Home Institution *
Academic Department *
Academic Discipline (if different)
Rank
Level of English Language Proficiency *
Please list some of the courses that you teach at your university *
Please select one of the following "Group I" courses to attend (Course I): *
Please select one of the following "Group I" courses to attend (Course II): *
Please select one of the following "Group II" courses to attend: *
Please describe what you expect to derive from your participation in the "Teaching in English at Montclair" program: *
Visa Information

A description of the section goes here.
Have you previously been to the US as a J1/J2 visitor? *
If yes, then please submit copies of all previously issued DS-2019 forms
Program 1: From MM / DD / YYYY
Program 1: To MM / DD / YYYY
Program 2: From MM / DD / YYYY
Program 2: To MM / DD / YYYY
Program 3: From MM / DD / YYYY
Program 3: To MM / DD / YYYY
Medical Insurance Compliance Agreement:

Required Medical Insurance

J-1 Exchange Visitors are required by law to have medical insurance for the duration of their stay in J status. In addition, all dependents on J-2 status accompanying the scholar must also maintain required medical insurance. The insurance must be maintained for the duration of your J visa program.

We recommend that you purchase medical insurance before traveling to the United States so that you are covered beginning on the day that you arrive. You may purchase a plan for your home country or refer to one of the following internet links for an insurance plan. When you select an insurance plan you will want to consider the cost of the plan and make sure that it provides the minimal required coverage.

Below are links to several insurance companies:

www.usnetcare.com/health_plans.aspx
www.hthstudents.com/students_plans.cfm
www.wallach.com
www.compassbenefit.com

Failure to maintain the required medical insurance amount will result in termination of your J exchange visitor program in the United States.

Note: Medical insurance policies generally do not cover pre-existing health conditions that may require treatment in the US. You may be required to pay cash for such treatment.

Minimum Medical Insurance Required:
1. Medical Benefits of at least $50,000 per person per accident or illness;
2. Repatriation of remains in the amount of $7,500: and
3. Expenses associated with medical evacuation in the amount of $10,000.

In addition, the medical insurance policy that you purchase to cover the minimum required amounts must not have a deductible that exceeds U.S. $500 per accident or illness.
I do attest that I will apply with the terms and conditions of the J-1/J-2 mandatory health insurance requirments as outlined above *
Yes No
I understand that I jeopardize my exchange visitor status if I fail to comply: *
Yes No
Full Name * First Last
Today's Date * MM / DD / YYYY
Do Not Fill This Out

Wufoo

Education

Visa Information