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:
New
York International Group, Inc.
An
affiliate of IMG
The Empire State Building
350 Fifth Avenue Suite 3304, New York, NY 10118
Tel: 212.268-8520 800.804.5763
Fax: 212.268-8524
E-mail: info@nyig.com
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#_______________________________ Name__________________________________ Address________________________________ 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.