Mr. Ms.     Last Name:
First Name:
Initial:
Home Country Address:
             
             
City/State:
Postal Code/Zip Code:
Country:
Date of Departure from home country (mm/dd/yy)
Country of Destination:
If your country of destination is the U.S., furnish visa type
Passport From Country (Applicant):
Passport From Country (Spouse/Child):
Beneficiary:
Relationship:
  (You will be the beneficiary for your spouse and dependent children)
If you received plan information through your professional association, please furnish Name of Association:
Address of Correspondence ( in care of ):
Name:
Address:
              
City:
State:     Zip Code:
Work Phone:
Home Phone:
Email Address:

Requested Effective Date of Coverage:
(month/date/year)

Requested Term of Coverage: months

Refund of Premium Full refund of premium is considered only upon written request. Premium refunds are calculated from the date written request is received by the Administrator. Full refund of premium is made if written request is received prior to the Effective Date of coverage. After the Effective Date, premium for the first 6 months of coverage is considered fully earned and non-refundable. If you are issued a Period of Coverage for 7 or more consecutive months, and will return to your Home Country/Country of Residence earlier than expected, unused premium for remaining whole months, exclusive of the first 6 months, will be refunded. Remaining whole months are calculated from the date written notice is received up to the termination date of the Period of Coverage in effect.

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