Worldwide Major Medical Plan Application

Plan Highlights Outline Approximate Premium Rates Instructions
WW 10/04 Travel Insurance Services, PC#
To be eligible for this coverage, you must reside outside the United States for more than 5 months per year. Benefits may be assignable. Benefits are subject to all terms, limitations and conditions outlined in your certificate. Please read your certificate carefully once you receive it.
  
Plan Type

Excluding USA Including USA

Proposed Insured First _____________________ Middle _____________________ Last _____________________
Non-US Address _____________________________________________________________________________
 _________________________________________ Daytime Phone Number ________________
US Address_____________________________________________________________________________
 _________________________________________ Daytime Phone Number ________________
Personal Info. Date of Birth _____________________ Height __________ Weight __________ Sex ___M ___F
Citizen of what country _____________________ Country of Residence ____________________________________
Occupation _____________________ Details of Duties _________________________________________
Last Medical Attendant _____________________ Reason Last Seen _______________________________________
Address _______________________________________________Date Last Seen _________________
Time outside US (months) ___________________ Deductible Requested _________________________
Desired Effective Date ________________________ (Earliest effective date is 24 hours after Underwriting approval.)
Optional Benefit Hazardous Sports/Activities: Specify Sport(s) or Activities _____________________________
Global Medical Transportation
War Coverage
   

Questions 1-22 must be answered to receive a consideration for coverage. For ALL questions that you answer "YES," please provide details of the medical condition including treatment, dates, name, address and phone number of attending physician, diagnosis, prognosis, and present course of treatment on a separate sheet. Please attach these responses to this application. The Underwriters may request additional medical information.

YES NO
1) During the past 5 years, have you been diagnosed with any medical condition, received treatment (including medications and consultations), or been hospitalized for any medical, mental, or nervous conditions?
YES NO
2) Are you currently disabled or unable to perform normal activities?
YES NO

3) Have you ever been declined or accepted on a modified basis for life, disability or medical insurance?

YES NO
4) Have you ever received treatment or joined an organization for alcoholism or drug dependency?
YES NO
5) Have you been diagnosed or treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS related complex (ARC), Lymphadenopathy Syndrome, or any Immune System Disorder?
Have you EVER been treated for, or have been told that, or have reason to believe that you have any diseases, conditions, medical problems, disorders, sicknesses or problems relating to any of the following:
YES NO
6) Heart?
YES NO
7) Blood Vessels or circulatory system?
YES NO
8) Blood Pressure?
YES NO
9) Diabetes or glands?
YES NO
10) Cancer, tumor, cyst or growth?
YES NO
11) Stomach, bowel or intestines?
YES NO
12) Kidney, liver or gall bladder?
YES NO
13) Lung or respiratory system?
YES NO
14) Sight or Hearing?
YES NO
15) Mental or nervous system?
YES NO
16) Bone, skeleton, muscles, joints or skin?
YES NO
17) Allergy?
YES NO
18) Epilepsy?
YES NO
19) Genito-urinary system?
YES NO
20) Reproductive system?
YES NO
21) Have you ever been treated for or had any indication of physical disorder, injury or abnormality, not disclosed elsewhere on this application?
YES NO
22) Have you ever applied to Lloyd's for Medical Coverage in the past?
YES NO
23) Are you currently taking medication? Please provide reason and medication details.
Please remember to attach a separate sheet with all details to any YES answers above.
  

Declaration (Please Read Carefully)

I read and/or understand English. I have read the above statements. I declare that the above information is true and complete to the best of my knowledge and belief. Apart from the matters disclosed above, I am in good health and ordinarily enjoy good health. In the event of fraud, misstatements, concealment, or failure to disclose information on this application, whether by intentional or inadvertent, any insurance issued based upon this application may become void and no benefits will be payable.

Authorization

I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medically related facility, insurance company or other organization, institution or person that has records or knowledge of me or my health, to give to the Petersen International Underwriters.

Date ___________________ Signature of Proposed Insured _________________________________________

Authorization To Release Personal Information (HIPPA Compliant)

I AUTHORIZE any physician, medical practitioner, hospital, clinic, health care facility, other medical or medically related facility, insurance or reinsuring company, consumer reporting agency, employer having information available as diagnosis, treatment, and prognosis with respect to any physical or mental condition and/or treatment of me or my minor children to provide to Petersen International Underwriters, Inc., or to any agency authorized by Petersen International Underwriters, Inc to collect any and all such information by means of U.S. Post , fax or e-mail.

I AUTHORIZE Petersen International Underwriters to communicate with me/us or our representative via mail, phone, fax or electronic mail regarding quotations, underwriting, claims, coverage administration, or additional coverages from Petersen International Underwriters.

I UNDERSTAND the purpose of this Authorization is to allow Petersen International Underwriters, Inc., to determine eligibility for life or health insurance or claim for benefits under a life or health policy. Any information obtained will not be released by Petersen International Underwriters, Inc., to any person or organization EXCEPT to those persons or organizations needing such information in performing business or legal services in connection with my application, claim or as may be otherwise lawfully required or as I may further authorize.

I KNOW that I may request to receive a copy of this Authorization.

I UNDERSTAND that I may revoke this Authorization, except to the extent that Petersen International Underwriters, Inc. has acted in reliance upon this Authorization. My revocation must be submitted in writing to Petersen International Underwriters Inc. Any such revocation may also have an impact upon my Underwriting or claims processing.

I UNDERSTAND that I can obtain a complete copy of Petersen International Underwriters Inc. Privacy Policy either on Petersen International Underwriters, Inc. website or by contacting them directly and asking for a copy.

I AGREE that a photostatic copy of this Authorization shall be as valid as the original.

I AGREE this Authorization shall be valid for two years from the date shown below.

Signed this _______day of ______________20________ Signature of Proposed Insured ________________________________

Please read Petersen International Underwriter's Privacy Policy.

06/03

 

Instructions

  1. Read and understand the Major Medical Plan Highlights, Outline, and Approximate Premium Rates before applying for coverage.
  2. Print this application and complete hard copy (all pages). Complete one application per person. Please print neatly or type.
  3. Fax the completed application to our office, (925) 932-1820, in order to obtain a quote. A quote will be returned to you in approximately 4 - 5 business days.

Once you have received a quote, to purchase a policy:

  1. Make full premium check or money order payable to the plan administrator, Petersen International Underwriters. All payments must be in U.S. dollars drawn on a U.S. bank. Do not send cash.
  2. Mail your completed application with original signatures and full premium payment to:
    Travel Insurance Services
    2950 Camino Diablo, Suite 300
    Walnut Creek, CA 94597-3991USA
  3. The original application and full premium payment must be received by our office prior to policy release.

Please Note:

Underwriting time is normally 4 - 5 business days from 1) the date Travel Insurance Services (TIS) receives a copy of the completed application by fax.

The earliest effective date available is 24 hours after underwriting.

A Certificate of Insurance will be sent to you by first class mail. Upon receipt of your Certificate of Insurance, please read it carefully as the terms and conditions stated therein will prevail.

Questions?

Contact: Yvonne Lee or Sandy Franchebois

Fax: (925) 932-1820
Phone: (800) 937-1387 or (925) 932-1387

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