JF USA ( United Healthcare ) JF USA PLUS PLANNo overall maximum dollar limit on the policy . Plan deductible $ 100 ( In - network ) , $ 300 ( Out - of - Network ) Out - of - Pocket Maximum ( OOPM ) : In - Network $ 6 , 350 ( Per person ) , $ 12 , 700 ( Family ) Out - of - Network : $ 8 , 000 ( Per person ) , $ 16 , 000 ( Family ) Coinsurance : 80 % ( In - Network ) , 70 % ( Out - of - Network ) Preventive care : 100 % CoverNo limit or waiting period for Pre - ExistingMaternity covered . AGE RANGE DAILY RATEStudent 24 & Under $ 3 . 25 Student 25 - 30 $ 4 . 65 Student 31 - 40 $ 10 . 40 Student 41 - 70 $ 21 . 47 Spouse $ 21 . 23 Each Child $ 11 . 51 브로 셔 보 기 Enrollment FormJF USA PREFERRED PLANNo overall maximum dollar limit on the policy . Plan deductible $ 50 ( In - network ) , $ 300 ( Out - of - Network ) Out - of - Pocket Maximum ( OOPM ) : In - Network $ 5 , 000 ( Per person ) , $ 10 , 000 ( Family ) Out - of - Network : $ 7 , 000 ( Per person ) , $ 14 , 000 ( Family ) Coinsurance : 90 % ( In - Network ) , 70 % ( Out - of - Network ) Preventive care : 100 % CoverNo limit or waiting period for Pre - ExistingMaternity covered . AGE RANGE DAILY RATEStudent 24 & Under $ 3 . 71 Student 25 - 30 $ 5 . 29 Student 31 - 40 $ 11 . 45 Student 41 - 70 $ 24 . 47 Spouse $ 24 . 79 Each Child $ 11 . 54 International Student Insurance : JF USA 2016 - 2017 ( * required field ) Premium provided is only estimate and subject to final confirmation from the insurer Travel Dates Application Date ( mm / dd / yyyy ) January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2016 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 * Arrival Date ( mm / dd / yyyy ) January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2016 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 * Effective Date ( mm / dd / yyyy ) January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2016 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 For 1 Year Policy * Expiry Date ( mm / dd / yyyy ) January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2016 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Duration in Days Insurable Options * Beneficiary Please complete the beneficiary for flight accident Rate Options Plus Preferred Check here to purchase family plan Sum Insured ( USD ) unlimited Insurable Members * Family Name * Given Name * Birth Date ( mm / dd / yyyy ) * Gender * Insured 1 January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 M F Address The primary address you will be staying at while in Canada / USA * Street No . * Street Name Suite No . * City * Province / State AB - Canada BC - Canada MB - Canada NB - Canada NL - Canada NS - Canada NT - Canada NU - Canada ON - Canada PE - Canada QC - Canada SK - Canada YT - Canada AL - USA AK - USA AZ - USA AR - USA CA - USA CO - USA CT - USA DE - USA DC - USA FL - USA GA - USA HI - USA ID - USA IL - USA IN - USA IA - USA KS - USA KY - USA LA - USA ME - USA MD - USA MA - USA MI - USA MN - USA MS - USA MO - USA MT - USA NE - USA NV - USA FA - USA FR - USA NC - USA ND - USA NH - USA NJ - USA NM - USA NY - USA OH - USA OK - USA OR - USA PA - USA RI - USA SC - USA SD - USA TN - USA TX - USA UT - USA VA - USA VT - USA WA - USA WI - USA WV - USA WY - USA * Postal / Zip Code * Phone 1 Phone 2 Learning Institution * Name of Institution Address * Student ID Phone Fax Contact * Email Address Contact Phone Country of Perm . Residence ) Special Notes / Instructions tudent 24 & Under $ 2 . 86 $ 3 . 27 Student 25 - 30 $ 4 . 01 $ 4 . 57 Student 31 - 40 $ 7 . 16 $ 7 . 79 Student 41 + $ 14 . 60 $ 16 . 62 Spouse $ 15 . 00 $ 15 . 00 Each Child $ 9 . 79 $ 9 . 79 Plan Deductible $ 100 per Insured Person , per PolicyYear $ 300 per Insured Person , per Policy Year $ 50 per Insured Person , per Policy Year $ 300 per Insured Person , per Policy Year Out - of - Pocket Maximum $ 6 , 350 Per Insured Person , Per Policy Year $ 12 , 700 for all insured in a Family , per Policy Year $ 8 , 000 Per Insured Person , Per Policy Year $ 16 , 000 for all insured in a Family , per Policy Year $ 5 , 000 Per Insured Person , Per Policy Year $ 10 , 000 for all insured in a Family , per Policy Year $ 7 , 000 Per Insured Person , Per Policy Year $ 14 , 000 for all insured in a Family , per Policy Year Coinsurance 80 % of Preferred Allowance for Covered Medical Expenses 70 % of Usual and Customary Charges for Covered Medical Expenses 90 % of Preferred Allowance for Covered Medical Expenses 70 % of Usual and Customary Charges for CoFeatures : International students or Scholars who are engaged in educational activities in U . S . Have not obtained permanent residency status in the U . S . Must actively attend class for at least the  rst 31 days after policy becomes e  ective Eligible students who do enroll may also insure their dependents . Eligible dependents are the student ’ s legal spouse and dependent children under the age of 26 . E  ective and Termination Dates : July 01 , 2015 to September 30 , 2016 ACA Compliant Plan Worldwide travel coverage , except in home country All deductibles and copays waived when treated at Student Health Center and paid at in - Network coinsurance . 24 / 7 multi - lingual claim assistance Paperless claim processing available online access to claim status , EOBs , ID Cards , network providers , correspondence and coverage account information . UHCSR Mobile App available to download ID card , to provide search , and check claim status . Nurse - line and student assistance program * Refunds of premiums are allowed only upon entry into the armed forces or ineligibility Age JF USA PlEligibility : Features : International students or Scholars who are engaged in educational activities in U . S . Have not obtained permanent residency status in the U . S . Must actively attend class for at least the  rst 31 days after policy becomes e  ective Eligible students who do enroll may also insure their dependents . Eligible dependents are the student ’ s legal spouse and dependent children under the age of 26 . E  ective and Termination Dates : July 01 , 2015 to September 30 , 2016 Hospital room and board expense Hospital emergency room visit Intensive care Hospital miscellaneous expense Surgery Assistant surgeon Anesthetist Registered nurse ’ s services Physician ’ s visits Day surgery miscellaneous Prescription drugs Diagnostic X - ray services and laboratory procedures CAT Scan / MRI Physiotherapy Radiation therapy Chemotherapy Durable medical equipment Ambulance services Accident dental treatment Mental illness treatment Substance use disorder treatment Complications of pregnancy Elective abortion Preventive care service Pediatric Vision Care and Pediatric Dental Service Repatriation and Evacuation AD & D Please refer to Policy Brochure and wording for detailed coverage , limits and co - insurance factors . B 공유 하 기 글 요소 사업자 정보 표시 | | | 사업자 등록 번호 : -- | TEL : -- | 사이버 몰의 이용 약관 바로 가 기