J-1 EXCHANGE VISITOR (DS2019) EXTENSION FOR SCHOLARS

Transcription

1 International Programs Laurel Hall on the Oval Fort Collins, CO Phone: (970) Fax: (970) J-1 EXCHANGE VISITOR (DS2019) EXTENSION FOR SCHOLARS THIS HANDOUT OUTLINES THE PROCEDURES TO FOLLOW IF YOU NEED TO EXTEND YOUR PERMISSION TO STAY IN THIS COUNTRY TO ACHIEVE YOUR ORIGINAL OBJECTIVE AS A J-1 EXCHANGE VISITOR. WHEN TO EXTEND YOUR PERMISSION TO STAY IN THE U.S. WILL EXPIRE 30 DAYS AFTER THE END DATE SHOWN IN ITEM 3 OF YOUR DS PLEASE NOTE THAT YOU ARE NOT ELIGIBLE TO WORK DURING 30-DAY GRACE PERIOD, BUT ARE ELIGIBLE TO REMAIN IN THE UNITED STATES. UNDER FEDERAL REGULATIONS, IF AN EXTENSION IS NEEDED, IT MUST BE COMPLETED BY THE EXPIRATION DATE ON YOUR DS ELIGIBILITY YOU ARE ELIGIBLE TO APPLY FOR AN EXTENSION OF STAY IF: YOU ARE WORKING TOWARD THE OBJECTIVE SHOWN ON YOUR MOST RECENT DS-2019; YOU ARE MAINTAINING YOUR STATUS AS A J-1 EXCHANGE VISITOR; YOU CAN DEMONSTRATE ADEQUATE FUNDING FOR THE PERIOD OF THE PROPOSED EXTENSION; AND YOUR EXTENSION WILL NOT CARRY YOU BEYOND FIVE YEARS AS A J-1 VISITING PROFESSOR OR RESEARCH SCHOLAR, OR SIX MONTHS AS A SHORT-TERM SCHOLAR. YOU HAVE ADEQUATE HEALTH INSURANCE COVERAGE FOR YOU (AND ANY DEPENDENTS). PROCEDURES AT LEAST 30 DAYS BEFORE YOUR PERMISSION TO STAY EXPIRES, PLEASE PROVIDE THE FOLLOWING ITEMS TO THE INTERNATIONAL STUDENT AND SCHOLAR SERVICES OFFICE: A. J-1 EXCHANGE VISITOR EXTENSION REQUEST FORM B. LETTER FROM ADVISER STATING DURATION OF EXTENSION C. ADEQUATE FUNDING OR PROOF OF FINANCIAL SUPPORT I. IF FUNDED BY CSU, A LETTER FROM DEPARTMENT INDICATING THE SUFFICIENT AMOUNT. II. IF FUNDED BY ANOTHER SOURCE PLEASE SUPPLY A LETTER FROM YOUR SPONSOR SHOWING A FINANCIAL COMMITMENT FOR THE EXTENSION PERIOD ALONG WITH AN ACCOMPANYING BANK STATEMENT. D. SIGNED HEALTH INSURANCE COMPLIANCE FORM E. ADMINISTRATION FEE OF $45.00 (CHECK/MONEY ORDER MADE PAYABLE TO CSU ) FINANCIAL SUPPORT INFORMATION: BEFORE A DS2019 DOCUMENT CAN BE ISSUED, PROOF OF ADEQUATE FINANCIAL SUPPORT MUST BE PROVIDED WITH THIS APPLICATION. MINIMUM FUNDING REQUIREMENTS FOR J-1 EXCHANGE VISITORS: ESTIMATED COSTS: LIVING EXPENSES PER MONTH LIVING EXPENSES PER YEAR Research Scholar/Professor/Short Term $ $17400 Scholar/Specialist ADDITIONAL EXPENSES: Spouse $ $ Child $ $

2 1024 Campus DelivERY J-1 EXCHANGE VISITOR EXTENSION REQUEST FORM (SCHOLAR) FULL LEGAL NAME AS IT APPEARS ON YOUR PASSPORT: FAMILY NAME (LAST NAME) MIDDLE NAME GIVEN NAME (FIRST NAME) CSU ID #: - - TODAY S DATE LOCAL ADDRESS: NUMBER AND STREET APT.# CITY STATE ZIPCODE LOCAL PHONE NUMBER: ( ) WORK PHONE NUMBER ( ) ADDRESS: COUNTRY OF CITIZENSHIP: DATE OF BIRTH: (MONTH/DAY/YEAR) ORIGINAL U.S. ENTRY DATE: EXTENSION DATES: START DATE END DATE DO YOU HAVE DEPENDENTS CURRENTLY IN THE U.S.? YES NO IF YES, HOW MANY? ARE YOU SUBJECT TO THE 2-YEAR HOME RESIDENCY REQUIREMENT? HAVE YOU APPLIED FOR A WAIVER OF THIS REQUIREMENT? YES YES NO NO IF YES, HAS YOUR WAIVER BEEN GRANTED? YES NO SUBMISSION CHECKLIST: J-1 EXCHANGE VISITOR EXTENSION REQUEST FORM LETTER FROM ADVISER STATING DURATION OF EXTENSION ADEQUATE FUNDING OR PROOF OF FINANCIAL SUPPORT I. IF FUNDED BY CSU, A LETTER FROM DEPARTMENT INDICATING THE SUFFICIENT AMOUNT. II. IF FUNDED BY ANOTHER SOURCE PLEASE SUPPLY A LETTER FROM YOUR SPONSOR SHOWING A FINANCIAL COMMITMENT FOR THE EXTENSION PERIOD ALONG WITH AN ACCOMPANYING BANK STATEMENT. SIGNED HEALTH INSURANCE COMPLIANCE FORM ADMINISTRATION FEE OF $45.00 (CHECK/MONEY ORDER MADE PAYABLE TO CSU)

3 J-1 EXCHANGE VISITOR HEALTH INSURANCE REQUIREMENTS ACCORDING TO IMMIGRATION REGULATIONS (22 CFR S62.14), J-1 EXCHANGE VISITORS AND ACCOMPANYING J-2 DEPENDENTS ARE REQUIRED TO MAINTAIN COMPREHENSIVE MEDICAL INSURANCE WITH EVACUATION AND REPATRIATION COVERAGE THAT MEETS U.S. GOVERNMENT MINIMUM REQUIREMENTS BEGINNING ON THE START DATE OF THE J-1 PROGRAM (INDICATED IN ITEM 3 OF THE DS-2019) CONTINUING TO THE END OF THE J-1 PROGRAM. THERE CANNOT BE ANY BREAKS OR LAPSES IN INSURANCE COVERAGE EVEN IF ONE TRAVELS OUTSIDE THE U.S FOR AN EXTENDED PERIOD OF TIME DURING THE J PROGRAM. AS PER THE U.S DEPARTMENT OF STATE REGULATIONS, ISSS IS REQUIRED TO TERMINATE THE SEVIS RECORD OF AN EXCHANGE VISITOR WHO: 1) DOES NOT PROVIDE ISSS WITH A VALID INSURANCE COMPLIANCE FORM BY THE START OF THE CSU J PROGRAM; AND 2) DOES NOT SUBMIT AN UPDATED INSURANCE COMPLIANCE FORM WHEN THE PREVIOUSLY REPORTED INSURANCE EXPIRES OR S/HE SEEKS TO EXTEND THE J-1 PROGRAM. THE WILLFUL FAILURE TO CARRY THE REQUIRED INSURANCE FOR YOURSELF AND, IF APPLICABLE, YOUR DEPENDENTS, OR MATERIAL MISREPRESENTATION OF INSURANCE COVERAGE WILL RESULT IN THE TERMINATION OF YOUR J PROGRAM AND LEGAL STATUS IN THE U.S. COMPREHENSIVE INSURANCE MINIMUM REQUIREMENTS STARTING MAY 15, 2015: The J insurance coverage must provide the following minimum coverage: Minimum medical benefit of $100,000 per person per accident or illness; Deductible that does not exceed $500 per accident or illness; Minimum repatriation of remains in the amount of $25,000; Minimum medical evacuation expenses in the amount of $50,000; and Co-insurance paid by J-1 not to exceed 25% of covered benefits per accident or illness. Insurance policies: May require a waiting period for pre-existing conditions that is reasonable as determined by current industry standards; and Must not unreasonably exclude coverage for the perils inherent to the activities of the exchange program in which you participate. Any policy, plan, or contract secured to fill the J insurance requirements must at minimum be: Underwritten by an insurance corporation having: o An A.M. Best rating of A- or above; or o A McGraw Hill Financial/Standard & Poor Claims-paying Ability rating of A- or above; or o A Weiss Research, Inc. rating of B+ or above; or o A Fitch Ratings, Inc. rating of A- or above; or o A Moody s Investor Services rating of A3 or above; or Be backed by the full faith and credit of the exchange visitor s home country; or Part of a health benefits program offered on a group basis to employees or enrolled students by a designated sponsor; or Offered through or underwritten by a federally qualified Health Maintenance Organization or eligible Competitive Medial Plan as determined by the Centers of Medicare and Medicaid Services of the U.S. Department of Health and Human Services

4 If you are a paid employee of CSU, you may be eligible for medical insurance coverage depending upon the terms of your appointment. Please check with your hiring department to verify your eligibility. IF YOU ARE A CSU EMPLOYEE ELIGIBLE FOR HEALTH INSURANCE, PLEASE BE AWARE OF THE FOLLOWING: THE ONLY CSU POLICY THAT MEETS THE MEDICAL AND DEDUCTIBLE MINIMUM REQUIREMENT FOR THE J-1 VISA IS THE ANTHEM POINT OF SERVICE(POS)PLAN. IF YOU ARE ENROLLED IN THIS INSURANCE YOU WILL NEED TO ALSO ENROLL IN AN ADDITIONAL PLAN WHICH PROVIDES REPATRIATION AND MEDICAL EVACUATION. IF YOU CHOOSE THE CSU GREEN OR GOLD PLAN YOU WILL NEED TO ALSO ENROLL IN AN ADDITIONAL PLAN THAT MEETS ALL THE J-1 MINIMUM REQUIREMENTS. THESE INSURANCE PLANS DO NOT MEET THESE REQUIREMENTS. For further information: All other J-1 Exchange Visitors must obtain your own private insurance that meets the minimum requirements. PLEASE NOTE: ISSS DOES NOT REVIEW POLICIES TO DETERMINE MINIMUM REQUIREMENTS YOU MUST CONSULT DIRECTLY WITH THE INSURANCE COMPANY. WE DO NOT ENDORSE OR RECOMMEND ANY ONE INSURANCE PROGRAM OVER ANOTHER. THE FOLLOWING IS A LIST OF INSURANCE COMPANIES AVAILABLE ONLINE: *AMA & Associates Associate Insurance Plans International, Inc. *BETiNS *CMI Insurance Compass Benefits *Co-ordinated Benefit Plans, Inc. and Cultural Insurance Services International (CISI) *FrontierMEDEX *Gallagher Koster *GatewayConnexions International Plans Health Benefit Concepts, Inc. HTH Worldwide *Insurance for Students, Inc. - IFS *International Medical Group (IMG) *International Student Insurance On Call International *The Harbour Group *Trawick International, Inc. *T.W. Lord & Associates Electronic mail to: [email protected] *VISIT Wallach & Company *Companies that have a star in front of them offer repatriation and medical evacuation insurance that you can purchase separately.

5 Name: CSU Start Date CSU End Date Please check one of the following: 1. I am enrolled in the Anthem Blue Point of Service Plan and a separate policy for repatriation and Medical Evacuation (Please provide information below). EVACUATION & REPATRIATION COVERAGE: The policy indicated below will cover (check all that apply): Me, the J-1 primary All of my J-2 dependents Insurance Company Name: Company Address: INSURANCE COMPLIANCE INFORMATION Company Phone: Company Policy/Group Number: Insurance Start Date: Insurance End Date: 2. I am enrolled in the Anthem GREEN or GOLD Plan and a non-csu plan which meets all of the J-1 Requirements (Please provide information below). 3. I am enrolled in a non-csu plan which meets all of the J-1 requirements. (Please provide the information below). COMPREHENSIVE MEDICAL/HEALTH INSURANCE COVERAGE WHICH INCLUDES MEDICAL EVAUCATION AND REPATRIATION The policy indicated below will cover (check all that apply) Me, the J-1 primary All of my J-2 dependents Insurance Company Name: Company Address: Company Phone: Company Policy/Group Number: Insurance Start Date: Insurance End Date: I certify under penalty of perjury that the above information is true and correct. I confirm my, and if applicable, my J-2 dependent(s), insurance coverage meets the U.S. Department of States requirements as outlined in 22 CFR S I understand it is my responsibility to provide proof of continuous insurance coverage to ISSS throughout my J program. I understand that if I fail to obtain and maintain adequate health, repatriation, and evacuation insurance for myself and my J-2 dependents (if applicable) for the duration of the J program, Colorado State University will be required to terminate my J program which will result in my loss of my legal J-1 immigration status and the J-2 status of any dependents accompanying me. Signature: Date