InterMedical™ Insurance Enrollment Form

Plan HighlightsOutline of Coverages RatesFAQs
Please read the InterMedical™ Enrollment Details and Instructions before completing this enrollment.
This plan is currently not available to insureds that reside in Idaho, Massachusetts, Minnesota, or Washington and/or insureds traveling from outside the U.S. to Idaho, Massachusetts, Minnesota, or Washington. Please call us at 1-800-937-1387 to learn about other plans that may be available.

Insured Last Name ________________________________, First _____________________________ Initial ______

Home Country Address ______________________________________ City _____________________________

State ______ Zip Code _________Daytime Phone (_____) ______ - ________

Trip Destination ________________________________________

Name ________________________________

Address ______________________________

City _________________State __ Zip Code ____

Home Phone (_______) _______ - _______

Business Phone (_______) _______ - _______

I hereby subscribe to the Group Insurance Trust (District of Columbia) 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 with its principal place of business in New York, NY. 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) __________

Travel Dates (month) _____ (day) _____ (year) _____ thru (month) _____ (day) _____ (year) _____ In calculating your premium be sure to include both your departure and return dates.

*Note: The maximum period of coverage is 364 days.

_ _/_ _/_ _ _ _

_______

_______ x

$_______ =

$_______

(You will be the beneficiary for your spouse and children.)

_ _/_ _/_ _ _ _

_______

_______ x

$_______ =

$_______

_ _/_ _/_ _ _ _

_______

_______ x

$_______ =

$_______

$________

No. of Days

No. of Travelers

AD&D Premium

______ x

$3.00 =

$_______

$_______

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 364 days.

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

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

Expiration Date
Coverage will terminate on the earliest of:

1. the return of the Insured Person to his home country;
2. 364 days after the effective date of coverage; or
3. 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 payment 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, 3070 Riverside Drive, Columbus, OH 43221, 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:

1. Write out your check as you normally would.
2. Write "check-by-fax" in the memo of your check.
3. Make a clear photocopy of your check on white paper (to make faxing easier).
4. 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.
5. 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.
6. Fax check and completed enrollment form to (610) 537-9818.
7. 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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