Exchange Teacher/Dependent Insurance Form

Today's Date

Teacher first and last name

Teacher's Passport Number

Compliant Coverage:

Federal law requires that all Exchange Visitors and accompanying spouse/dependents are required to have medical insurance and medevac/repatriation insurance in effect for the duration of their exchange program.

Exchange visitors are required to have:

(1) Medical benefits of at least $100,000 per accident or illness;

(2) Repatriation of remains in the among of U.S. $25,000; and

(3) Expenses associated with Medical Evacuation in the amount of U.S. $50,000.

(4) A policy secured to fulfill the insurance requirements shall not have a deductible that exceeds U.S. $500 per accident or illness

(5) Co-insurance may not be greater than 25%

These standards are specified in the Exchange Visitor Program regulations, 22 CFR Part 62.14.

Sagamore has partnered with Envisage Global Insurance (EGI) to provide at least one option for compliant insurance to our teachers and dependents that meets the requirements outlined above and includes HEALTH, MEDEVAC AND REPATRIATION coverage. This can supplement or replace any health insurance that you receive through your school. Typically plans offered by schools are not compliant with these State Department regulations, so adding on this EGI option to a school plan would provide a more comprehensive and compliant plan.

The 2025 cost for EGI coverage is $70 per person per month. (Subject to change based on yearly increases to rates charged by insurance providers).

* Please see the last question for a link to the plan brochure.

I understand that insurance that meets the State Department requirements is necessary to remain in the Global Teach Exchange program.

I need to sign up for the EGI insurance coverage for myself and/or my family members OR make a change to our EGI coverage.I don't need this because I already have coverage that meets the requirements. Please use the space below to explain why you do not need this coverage and upload supporting documents.

Please explain how you have health, medevac and repatriation insurance that is current and meets the requirements. Please submit these documents in English (you will have to request the documentation from your provider in English). Upload supporting documents below.

Supporting Document

What do you need to do?

I need to SIGN UP for EGI insurance for the FIRST TIME (no one in my family currently has EGI insurance)I need to ADD A NEW PERSON to the EGI insurance (some family members are already using EGI)I need to MAKE A CHANGE to my family's EGI insurance coverage

What changes need to be made to your/your family's EGI insurance coverage? If you need to drop the coverage, please be very specific about which family members need coverage dropped, what date the coverage needs to be dropped and the reason. IF you need to switch to the Medical Evacuation & Repatriation ONLY plan, please note that here. (This supplemental plan will cost $65 per person, per year and you must have Muface coverage in place or another approved private plan. We will need to have a copy of your coverage certificate on file). We will follow up with you if we have questions.

Contact Information