Patriot Travel Insurance - Enrollment

PATRIOT TRAVEL MEDICAL INSURANCEsm
Medical Insurance for Citizens Traveling Abroad


To Enroll in Patriot Travel Medical Insurancesm:

1. Print this Page
2. Complete entire Enrollment Form.
3. Please make check or money order payable to IMG and enclose in envelope with signed Enrollment Form.
4. Mail to:

IMG
407 North Fulton Street
Indianapolis, Indiana
46202 U.S.A.

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).

Patriot Internationalsm Opt 1__ Opt 2__  Opt3___
Patriot Americasm Opt 4__   Opt 5__  Opt6__
ExPatriot Plussm Opt 7__  Opt 8__ Opt 9__ Opt 10__

 

Names of Persons to be insured Date of Birth Monthly Premium 15 Day Premium
Applicant _______________________ ___/___/___ ___________ ___________
Spouse _______________________ ___/___/___ ___________ ___________
Child _______________________ ___/___/___ ___________ ___________
Child _______________________ ___/___/___ ___________ ___________
Please Attach additional sheet for more children ___________ ___________
Total (A) Total (B)
Requested Effective Date ___/___/____

Expected Date of Departure____/____/___

Date of Return to Home Country ____/___/___

 

_________ x _________ = _________ + _________ = _________
(A) Number of months (B) (C)

_________ X _________ = _________ X _________ + _________ = $_________
(C) Deductible factor
(see below)
(D) Sports Rider Factor
(see below)
US$15.00 Optional Overnight,
Fax confirmation or Special Correspondence
Total Premium
Deductible Discount factor
$250 1
$500 .90
$1000 .80
$2500 .70
Sports factor 1.2

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.

x___________________________________________

Signature of Insured or Proxy

Date__________________ Phone_________________

Address_____________________________________

____________________________________________

Selling Agent Use Only

Agency# 12588

Name      Alexandra De Catalogne

e-mail alexdecat@aol.com

City________________State____Zip Code____

PATRIOT INTERNATIONALsm
For U.S. CitizensTravel Medical Insurance for U.S. citizens traveling abroad. Patriot Internationalsm has 3 benefit options.

PATRIOT AMERICAsm
For Non-U.S. Citizens U.S style Travel Medical Insurance for non-U.S. citizens traveling outside their country of citizenship. Patriot America has 3 benefit options.

EXPATRIOT PLUSsm
For All Long Term Travelers. ExPatriot Plussm must be issued for a minimum of 6 months and is renewable for up to 2 years. ExPatriotsm has a $1,000,000 benefit.

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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