International Student and Scholar Services
Office of Internationalization, University of Denver
2200 S. Josephine St., Denver, CO 80208
Phone (303) 871-4912 Fax (303) 871-4910
INSURANCE REQUIREMENT ATTESTATION FORM
THIS FORM MUST BE COMPLETED, SIGNED AND RETURNED TO INTERNATIONAL
STUDENT & SCHOLAR SERVICES BEFORE A DS-2019 CAN BE ISSUED FOR A NEW
SCHOLAR, FOR EXTENSION OF STAY OR FOR A DEPENDENT.
Required Insurance Information
Under the regulations of the United States Department of State all individuals who receive a Form
DS-2019 (J visa document) and enter the U.S. in J-1 exchange visitor status are required to have
medical insurance to cover themselves and any accompanying J-2 dependents for the duration of
If you will not be a benefits-eligible employee, DU requires you and your J-2 dependents to
purchase the Global Visiting Scholar International Health Plan from International Student
Insurance. Enroll in the plan at
If you will be a benefits-eligible employee, you and your J-2 dependents must
• Enroll in a DU plan that meets the Department of State requirements for a J Exchange
Visitor (Kaiser Permanente HMO or Tier 1 of the Triple-Option POS Plan); and
• Buy supplementary insurance for medical evacuation and repatriation of remains (brochures
available at ISSS).
• Enroll in the Global Visiting Scholar International Health Plan.
Failure to comply with this requirement will result in the
termination of the exchange visitor's program!
I understand that as a J-1/J-2 visa holder, I am required to maintain health insurance as specified
above for myself and any accompanying J-2 dependents. I hereby affirm that I have, or will have
by the time I begin my visit at the University of Denver, the stated insurance for the effective
period of all valid forms DS-2019 issued to me.
(Exchange Visitor Signature)
(Exchange Visitor Name)
click to sign
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