Mr. Ms.     Last Name:
First Name:
Initial:
Home Country Address:
             
             
City/State:
Postal Code/Zip Code:
Country:
Describe International Exchange Activity:

Name of Sponsor or Host Organization/Institution/Company:

Most recent day of arrival in U.S.A.: (month/date/year)
Visa Type:
Passport Number:
Visa Number:
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 in U.S.A.for Correspondence:
Name:
Address:
              
City:
State:     Zip Code:
Work Phone:
Home Phone:
Have you been insured by us before ? Yes   No
If yes, then Certificate No.
Premium, Eligibility Criteria, Plan Benefits, Limitations and Exclusions are subject to change. Coverage is issued according to plan specifications and rates in effect at time of enrollment.

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

Requested Term of Coverage: 15-Day Plan or months

Note: Refund of Premium
Full refund of premium is made if written request is received by Gateway Administrator prior to the effective date of coverage. Premium is considered fully earned and is not refundable for any term of coverage issued for six months or less. if you are issued a term of coverage for seven or more consecutive months, and must return to your home country earlier than expected, unused premium for whole months that remain from the date we received your written notification will be refunded.

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