The United States Government, Department of State, Federal Code 22, Section 514 establishes as a condition to receive a J-1 or J-2 visa that the participant must carry and maintain adequate health insurance coverage for him or her and for his or her family members. Government regulations stipulate that if the participant fails to maintain health insurance, the institution must terminate the program participant. Therefore, as part of the requirements to participate in our Program, we ask you to certify that you will comply with the health insurance coverage.

FOR VISITORS THAT WILL NOT BRING ANY DEPENDENTS (SPOUSE, CHILDREN)

I certify that I will carry and maintain adequate health insurance as stated below:

☐	I have or will have health insurance with the University of Puerto Rico.

☐	I have or will have health insurance with a well-recognized company in USA or Puerto Rico.

Identify and provide copy of the coverage:

☐	I have or will have another type of health insurance (If you select this alternative, you accept that if a medical emergency occurs to you, you will be responsible for the medical hospital expenses).

Identify and provide copy of the coverage:

FOR VISITORS THAT WILL BRING DEPENDENTS (SPOUSE, CHILDREN)

I certify that I will carry and maintain adequate health insurance for me and my family as stated below:

☐	I have or will have health insurance with the University of Puerto Rico and it covers my family.

☐	I have or will have health insurance with a well-recognized company in USA or Puerto Rico and it covers my family.

Identify and provide copy of the coverage:

☐	I have or will have another type of health insurance that covers my family (If you select this alternative, you accept that if a medical emergency occurs to you or your Dependents, you will be responsible for the medical hospital expenses).

Identify and provide copy of the coverage:

I certify that I will carry or currently carry adequate health insurance. I also certify that I understand that my J-1 program will be immediately terminated if I fail to maintain health insurance for my family members and myself.

Print your name	Signature	Date

As soon as your DS-2019 has been approved, we will request you to bring evidence of the acquisition of the insurance(s).

Rev. Jan., 2017