InterMedical Insurance Printable Enrollment Form

InterMedical™ Insurance Enrollment Form

FAQs
Please read the InterMedical™ Enrollment Details and Instructions before completing this enrollment.

1. Insured's Information	Official Use Only: 0901/60M PC# 32701 Cert.#
Insured Last Name ________________________________, First _____________________________ Initial ______
Home Country Address ______________________________________ City _____________________________
State ______ Zip Code _________Daytime Phone (_____) ______ - ________ Passport Number _________________________
Country of Issue ____________________________________ Trip Destination ________________________________________

2. Emergency Contact

3. Agreement

Name ________________________________

Address ______________________________

City _________________State __ Zip Code ____

Home Phone (_______) _______ - _______

Business Phone (_______) _______ - _______

I hereby subscribe to the AIG Life Trust and enroll in the group coverage for which I am eligible under the group contract issued by the Insurance Company of the State of Pennsylvania, a member Company of the American International Group of Companies (AIG). I hereby certify that I have fully read, understand, and agree to the InterMedical™ Insurance Brief Outline of Coverages. The group policy provides limited medical expense benefits for pre-existing conditions. (Refer to Exclusions in the Brief Outline of Coverages). Refund of premium, less a $20 processing fee will be returned only if a written request is received by Travel Insurance Services prior to the effective date of coverage. After the effective date of coverage, the premium is considered fully earned and non-refundable.

Signature of Insured or Proxy _______________________________________________
Date (month) _________ (day) __________ (year) __________

4. Coverage Effective Dates	We request InterMedical™ Insurance to begin at 12:01 a.m. on the dates we are originally scheduled to depart on our trip, provided the premium and this completed form are received as set forth in the InterMedical™ Enrollment Details and Instructions below.
Travel Dates (month) _____ (day) _____ (year) _____ thru (month) _____ (day) _____ (year) _____ In calculating your premium be sure to include both your departure and return dates.

5. Calculating Your Payment - Basic Plans:
Travelers	Name	Date of Birth Month/Day/Year	Requested Plan A or B	No. of Days to be Insured	Daily Rate (from Rate Chart below)	Total Premium
A. Insured	________________________	_ _/_ _/_ _ _ _	_______	_______ x	$_______ =	$_______
Beneficiary	________________________	(You will be the beneficiary for your spouse and children.)
B. Spouse	________________________	_ _/_ _/_ _ _ _	_______	_______ x	$_______ =	$_______
C. Child	________________________	_ _/_ _/_ _ _ _	_______	_______ x	$_______ =	$_______
(Age 14 days - 18 years)		PREMIUM SUBTOTAL (Minimum premium $20)				$________
Optional Additional AD&D: (If desired, must be purchased for all travelers, for entire trip duration.)			No. of Days	No. of Travelers	AD&D Premium
			______ x	______ x	$3.00 =	$_______
TOTAL DUE						$_______

6. Payment Method	______ Check or money order enclosed, payable to Travel Insurance Services, for the Total Due. ___ MasterCard ___ VISA ___ DiscoverCard # ________________________________ Exp.Date ____/____
	Billing Address _________________________________________________________________________ Signature ____________________________________________________________ Date ______/______ Note: Coverage purchased by credit card is subject to validation and acceptance.
All Payments must be in U.S. dollars drawn on a U.S. bank. DO NOT SEND CASH. Mail completed application with check, money order or credit card information, or FAX with credit card information or payment via check-by-fax to: Travel Insurance Services, 2950 Camino Diablo, Suite 300, Walnut Creek, CA 94597-3991, USA. Fax (610) 537-9818, Phone (800) 937-1387 or (925) 932-1387.

Benefit Limits

Benefits Included	Plan A Limit	Plan B Limit
Maximum Stay	1 Year	1 Year
Illness and Injury Medical Expenses/Incident	$25,000	$100,000
Deductible/Incident	$50	$50
Emergency Evacuation	$50,000	$75,000
Bedside Visit	$1,500	$1,500
Escort of Minors	economy class airfare	economy class airfare
Accidental Death and Dismemberment	$10,000	$100,000
Repatriation of Remains	$7,500	$7,500
Optional AD&D Upgrade	Additional Limit
Accidental Death and Dismemberment	$400,000

Premium Per Insured Person Rate Charts

Basic Plans	Premium Per Day Per Person
	Plan A	Plan B
Ages through 69	$3.25	$5.00
Ages 70+	$7.50	$10.00

Optional AD&D Upgrade

AD&D Upgrade	Premium Per Day Per Person
All Ages	$3.00 additional

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Enrollment Details

Eligibility
Apply early to begin coverage when you leave your home country. Coverage is available to people who are traveling outside the U.S. and outside their home country, for up to one year.

Effective Date
Coverage begins at 12:01 a.m. on the latest of:

the departure of the Insured Person from his home country;
the date after the Insured Person's completed enrollment form and correct premium are postmarked to Travel Insurance Services; or
the requested effective date on the enrollment form.

Expiration Date
Coverage will terminate on the earliest of:

the return of the Insured Person to his home country;
one year after the effective date of coverage; or
the requested termination date on the Insured Person's enrollment form for which premium has been paid.

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Instructions

Read and understand the InterMedical™ Insurance Brief Outline of Coverages before applying for coverage.

Print the Enrollment Form and complete hard copy. Complete one enrollment per family (you, your spouse and your children age 14 days through 18 years traveling with you - children 19 and over will need to complete a separate enrollment). Incomplete enrollments are unacceptable and will be returned to you unprocessed.

Complete areas 1. through 6. Please print neatly or type.

To effect coverage, the completed enrollment form and full premium must be received by Travel Insurance Services by mail or fax. Fax (610) 537-9818. If leaving within 10 days, we suggest you Enroll Online .

Applications cannot be processed without credit card name, number & expiration date, check/money order or check-by fax payment. All payments must be in U.S. Dollars drawn on a U.S. Bank. Do not send cash. Minimum policy premium is $20. Maximum policy period is one year.

To MAIL your enrollment and payment
Mail your completed enrollment with full premium check, money order or credit card information (Master Card, Visa or Discover) to Travel Insurance Services, 2950 Camino Diablo, Suite 300, Walnut Creek, CA 94597-3991 USA.

To FAX your enrollment and payment
You may fax your completed enrollment with credit card information (Master Card, Visa or Discover) or when paying via "check-by-fax" to (610) 537-9818. If you use the "check-by-fax" payment method, please follow these guidelines:

Write out your check as you normally would.
Write "check-by-fax" in the memo of your check.
Make a clear photocopy of your check on white paper (to make faxing easier).
Rewrite the Fraction code on the photocopy above the check, as these small numbers are difficult to read on a fax. The Fraction code is the tiny set of numbers printed near the check number.
Be sure that the Routing and Checking account numbers are legible. (These are the long series of numbers at the bottom of the check.) If they are not easy to read, you may rewrite them near the original numbers on the photocopy.
Fax check and completed enrollment form to (610) 537-9818.
Do not mail your enrollment and check after faxing, as this causes unnecessary duplication.

Proof of Insurance
Correctly completed enrollments are processed within 1-3 business days after receipt. Your Confirmation of Insurance will be sent by mail to the home country address specified on the enrollment form unless otherwise instructed.

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