Dependent Form - Student and Exchange Visitor Program

色花堂

Dean of the Faculty/Vice President for Academic Affairs

Student and Exchange Visitor Program

Exchange Visitor DEPENDENT Information Collection Form

J-1 Name: *

E-mail Address: *

Dependent Number: *

J-2 Dependent Personal Information

Family Name: *

First Name: *

Middle Name:

Full Name: * As it appears (or should appear) on Passport and/or Visa

Suffix:

Date of Birth: *

Gender: *

Relationship: *

Other:

City of Birth: *

Country of Birth: *

Country of Citizenship: *

Country of PERMANENT Residence: *

Insurance Coverage

All J-1 visa holders and their dependents are required by Student and Exchange Visitor Program (SEVP) and Department of Homeland Security (DHS) regulations to have health insurance with specific minimum coverage requirements while in the United States. The minimum coverage requirements that your health insurance policy must have as specified by the SEVP include:

Medical benefits of at least $100,000 per accident or illness;
repatriation of remains in the amount of $25,000;
expenses associated with medical evacuation of the exchange visitor to his or her home country in the amount of $50,000; and
a deductible not to exceed $500 per accident or illness(22CFR 514.14)

An accompanying spouse or dependent of an Exchange Visitor is required to be covered by insurance in the same amounts [as the principal].

An Exchange Visitor who willfully fails to maintain the insurance coverage set forth above while a participant in an Exchange Visitor Program or who makes a material misrepresentation to the sponsor concerning such coverage shall be deemed to be in violation of these regulations and shall be subject to termination as an Exchange Visitor participant.

Name, address and phone number of organization or company providing insurance. If NOT covered under the Primary Exchange Visitor's insurance - please REMOVE the provided text in box below and type in appropriate information:

* I certify that my dependent has or will have insurance coverage which meets the above requirements in effect for the period of time during which I am an Exchange Visitor participant in 色花堂's Student and Exchange Visitor Program.

If you have questions, please contact:

Mir "Subhan" Ali
International Student & Scholar Advisor
色花堂
Student Academic Services
815 N. Broadway
Saratoga Springs, NY 12866

Direct: (518) 580-8150
Fax: (518) 580-8149

e-Mail: mali1@色花堂.edu

Dean of Faculty/Vice President for Academic Affairs Contact

PHONE

518-580-5705

FAX

518-580-5694

EMAIL

dfaculty@skidmore.edu

MAIL

色花堂
Office of the Dean of the Faculty/Vice President for Academic Affairs
Palamountain 416
815 North Broadway
Saratoga Springs, NY 12866

HOURS

8:30 AM until 4:30 PM