Office of International Affairs
Phone: (337) 482-6819 // Fax: (337) 262-1346
E-mail: email@example.com // Web: http://louisiana.edu/oia
Certification of Medical Health Insurance Coverage
J-1 Exchange Visitor
Expected Arrival Date: Expected Departure Date:
I certify that the above named individual and dependents have medical benefits of at least
$100,000.00 per accident or illness, repatriation of remains in the amount of $25,000.00, expenses associated
with medical evacuation of the exchange visitor to his or her home country in the amount of $50,000.00 and a
deductible not to exceed $500.00 per accident or illness.
Dates of Coverage: From: To:
Name of Medical Health Insurance Company Signature of Agent Representing Date
Medical Health Insurance Company
Please attach the following documents:
• Proof of the exchange visitors medical health insurance coverage (such as ID card or letter from insurance
• Verification of dates of coverage
• A description, in English, of the conditions of the medical health insurance coverage.
• If the medical health insurance is based on employee benefits provided to the exchange visitor’s parent,
documentation verifying the age through which the exchange visitor is eligible for coverage.
I certify that I have enrolled in the above medical health insurance program. I will continue to maintain this
coverage and will notify your office of any changes and provide appropriate documentation of any changes. I
will provide documentation of continuation of the required coverage upon request for extension of J-1 status.
By agreeing to and submitting this form, I acknowledge that the information provided about my medical health
insurance coverage is true and accurate and I understand that I must carry the requisite insurance for as long as I
am enrolled at the University of Louisiana at Lafayette. If this document contains any false, fraudulent or
misrepresented information, the University of Louisiana at Lafayette will have no responsibility (legal or
financial) to any health issues that apply to and have been incurred by me, including death. I acknowledge that I
am legally responsible for any and all medical expenses during my enrollment at the University of Louisiana at
Lafayette. Further, I understand that the Office of International Affairs along with Student Health Services
reserves the right to investigate the validity of private policy benefits in order to meet all listed requirements.
Signature of Exchange Visitor Date