Application For Insurance Coverage
APPLICATION FOR INSURANCE COVERAGE
Administered by HCC Medical Insurance Services Group
Group Number: AT16G126000 & AT16G12700
DESCRIPTION OF COVERAGE
Insurance does not cover dental/optical
A. Illness and accident coverage per incident: $100,000.00 USD
B. Emergency Medical Evacuation/Repatriation: $ 50,000.00 USD
C. Return of Mortal Remains: $ 25,000.00 USD
Insurance begins with the start date on your DS-2019 form and ends on the
completion date on your DS-2019 form.
*The deductible is the amount paid out of your pocket per each incident.
Insurance deductibles: $50.00 USD per incident or illness
Please check the program that you are applying for:
By submitting this application, I verify that I wish to be covered by the insurance program designed for the J-1 Training/Intern/Work and Travel program administered by HCC.
Family Name
Given Name
Middle Name
Insurance coverage during your 30 day grace period is not a mandatory requirement under the Department of State regulations; however, we highly recommend you purchase supplemental insurance to cover any time you are in the U.S. outside of the dates listed on your DS form. If you elect not to purchase supplemental insurance during the grace period, you acknowledge that any injury or illness that may occur during your grace period will not be covered by your insurance policy with HCC.
