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PATRIOT
TRAVEL MEDICAL INSURANCEsm
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Applicant information: Patriot Travel Medical Insurancesm Please print clearly (Circle one) Mr. Mrs. Ms. Last Name_______________________________ First Name___________________________Middle________________ Passport Number____________________________________ Issuing Country__________________________________ Send Confirmation of Coverage to: Name__________________________________________________________________________ Address________________________________________________________________________ City_________________________________State_________Zip Code__________________Country_____________ Beneficiary_________________________________________ Relationship to Applicant__________________________ Insured will be beneficiary for spouse & children Calculating Your Premium: Select the coverage plan and plan option: (Check one plan and one option).
Payment must be for total number of months you want coverage. Refund of premium will be made only if a written request is received by IMG prior to the effective date of coverage. After that, the premium is fully earned and non refundable. All payments must be made in US Dollars. Payment Method Check (To IMG) / Money Order (To IMG) / Mastercard / Visa / Amex Card #_____________________________________________ Expiration date___________ Phone________________________________ Name on Card________________________________________________Signature______________________________ If paying by credit card, I authorize IMG to bill my credit card account for the total charge as specified if Total Premium. Coverage purchased by credit card is subject to validation and acceptance by credit card company. The undersigned hereby subscribes to the Global Health, Accidental and Travel Insurance Trust, in Washington D.C. and enrolls in Patriot Travel Medical Insurancesm ( under contract by Sirius International Insurance Corporation (publ). If signed as proxy of the Insured, the undersigned warrants their authority of the signatory to bind insured. I understand this policy is not a general health insurance policy. It is intended for the use of the Insured and the Insured's dependents in the event of a sudden and unexpected illness or injury arising when the Insured is eligible for coverage under this insurance. This policy does not provide benefits for illness or injuries which existed during the five years prior to the effective date of this insurance. Further, insured agrees to exclusion of coverage for pre-existing conditions as defined here-in. I am in good health and I have not been diagnosed with and do not suffer from any Medical Condition for which I foresee that I may require treatment in the future or for which I intend to claim under this policy. The undersigned authorizes any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance agency, insurance company, group policy holder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial and employment status, of the Insured to provide this information to International Medical Groupsm, Inc. I understand that coverage under Patriot Internationalsm ( & or Patriot Americasm) is NOT Renewable and that I must pay premium for the entire coverage period in advance. Any successive enrollments in Patriot Internationalsm ( & or Patriot Americasm) are not renewals.
PATRIOT INTERNATIONALsm PATRIOT AMERICAsm EXPATRIOT PLUSsm Premiums effective through 12/31/99. *A dependent child is your child shown on the Enrollment Form under 18 years of age, traveling with you, and for whom premium has been paid. |
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