Health and Accident Insurance is mandatory for all J-1 Exchange Visitors and any J-2 family members during
their stay at the Florida Gulf Coast University. This is a requirement of the U.S. Department of State. This
Sickness and Accident Insurance Verification form is used by the Exchange Visitor to provide proof that he
or she is insured by the home government or by a company within the country of his or her legal residence.
The named Exchange Visitor/Scholar upon his or her arrival to Florida Gulf Coast University must present
proof of insurance coverage to the FGCU International Services Office.
The insurance policy must cover
the entire time period for which the DS-2019 Form is valid.
1. To Be Completed By The Exchange Visitor:
Exchange Visitor’s Name: ________________________________________________________
Name of Insurance Provider: ______________________________________________________
I authorize my insurance provider to release the following information to Florida Gulf Coast
Exchange Visitor’s Signature:________________________________ Date: _________________
2. To Be Completed By Insurance Provider:
Please verify that the insurance policy you have issued to the above named person meets or exceeds
the following requirements:
1. Medical benefits of at least $50,000 per accident
or illness;
2. Repatriation of remains in the amount of $7,500;
3. Expenses associated with the medical evacuation
of the Exchange Visitor to his/her home country in
the amount of $10,000;
4. A deductible not to exceed $500 per accident or
illness (may require a waiting period for pre-
existing conditions which is reasonable as
determined by current industry standards; also may
include provision for co-insurance under the terms
of which the exchange visitor maybe required to pay
up to 25% of the covered benefits per accident or
5. Shall not unreasonably exclude coverage for
perils inherent to the activities of the Exchange
Program in which the Exchange Visitor participates;
6. Any policy, plan, or contract secured to fill the
above requirements must, at a minimum, be:
(A) Underwritten by an insurance corporation
having an A.M. Best rating of “A-” or above, an
Insurance Solvency International, Ltd. (ISI) rating
of “A-i” or above, a Standard & Poor’s Claims-
paying Ability rating of “A-’ or above, or a Weiss
Research, Inc. rating of B+ or above; or
(B) Backed by the full faith and credit of the
government of the exchange visitor’s home country;
(C) Part of a health benefits program offered on a
group basis to employees or enrolled students by a
designated sponsor; or
D) Offered through or underwritten by a federally
qualified Health Maintenance Organization (HMO)
or eligible Competitive Medical Plan (CMP) as
determined by the Health Care Financing
Administration of the U.S. Department of Health
and Human Services.
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Please also indicate if family members (dependent children
and spouse) are covered: YES / NO
On behalf of the above named insurance company, I hereby certify that the insurance indicated covers all of the
above requirements. In addition, I certify that the insurance coverage is for the time period listed below, and I
have indicated above whether the coverage includes family members or not.
Name Insurance Company Official (print): ___________________________________________
Dates of Effective Coverage: ______________________________________________________
Authorized Signature of Insurance Company Official: ___________________Date:___________
Address: ______________________________________________________________________
State: _______________________________________ Country: __________________________
Phone: ________________________________ Fax: ___________________________________
(If Available) U.S. Phone__________________________________________________________
U.S. Address: ___________________________________________________________________
Please mail or fax this form to your client or directly to the following:
nternational Services Office For Information: E-MAIL:
Florida Gulf Coast University
International Services Office Tel: 239-590-7925
10501 FGCU BLVD South Fax: 239-590-7977
Fort Myers, FL 33965-6565
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