Study USA-HealthCare Printable Enrollment Form

Study USA-HealthCare™ Enrollment Form	Official Use Only:0304 Conf.# PC# 32701 Eff Date: ___/___/___ Date Rec'd: ___/___/___
Plan Highlights Plan Details Rates Please read the Study USA-HealthCare Instructions before completing this enrollment.

1. Insured's Information (Please Print Clearly)
Last Name	________________________________________	Email Address	________________________________________
First Name	________________________________________	Passport Number	________________________________________
Mailing Address	________________________________________	Country Issuing Passport	________________________________________
City	________________________________________	Visa Type	________________________________________
State/Province, Zip/Postal Code	________________________________________	I am an international student currently registered to study in the U.S.
Country	________________________________________	I am a U.S. registered student studying outside the U.S.
Phone	________________________________________	Name of school, college or university	________________________________________
2. Enrollment Type		3. Payment Choose one method. (See instructions below for details.)
	First Time Enrollment For Myself For Myself and Dependents	Enroll by Mail Payment: check credit card
	Dependent Enrollment Only	Enroll by Fax: Pay with credit card only (DO NOT mail originals.)
	Confirmation Number ______________________	Credit Card Type Visa MasterCard Discover
	Renewal for Self/Dependents	Card # ________________________________ Exp. ____ / ____
	Confirmation Number ______________________	Card Holder Name ________________________________
Plan Requested:	Plan A Plan B	Billing Address ________________________________
Months of Coverage (maximum 12 months): __________		City, State, Zip ________________________________
Requested Effective Date: (month/day/year) _____/____/_____		Signature ______________________________ Date ____ / ____

4. Rate Calculation		Arrival Date in Country of Study (month/day/year)	Monthly Premium	Add'l Medical Evacuation Premium (if applicable)	Total Monthly Premium	# of Months (max.12)	Total Payment
Name - Complete the form below for yourself and any dependents you are enrolling.		Arrival Date in Country of Study (month/day/year)	Monthly Premium	Add'l Medical Evacuation Premium (if applicable)	Total Monthly Premium	# of Months (max.12)	Total Payment
Insured Name	___________________________	____/____ /____	$_______	+ $_______	= $_______	x____	=_______
Insured Date of Birth (month/day/year) ____/____/____
Spouse Name	___________________________	____/____/____	$_______	+ $_______	= $_______	x____	=_______
Spouse Date of Birth (month/day/year) ____/____/____
Dependent Name	___________________________	____/____ /____	$_______	+ $_______	= $_______	x____	=_______
Dependent Date of Birth (month/day/year) ____/____/____
Subtotal							=_______
Administration Fee +							$ 5.00
OPTIONAL: Include your fax number: (_______) _______ - __________ for a rushed fax copy of Confirmation. Add $10.00							+_______
I hereby enroll in Study USA-HealthCare. All claims will be fully investigated. Premiums received by the Program Marketer / Insurance Company will be considered fully earned and non-refundable. Coverage under this program terminates if a covered Person enters military service and a pro-rata refund will be made from the date a written request is received. Otherwise, no refunds will be made. Signature of Insured or Proxy ____________________________________________________Date ____________						Total	$_______

Instructions

Read the Plan Details page.

Print this enrollment form and complete the hard copy (items 1-4) for you, your spouse, and your children (under age 18). Incomplete forms will not be processed and will be returned.

You may pay by check, money order, MasterCard, Visa or Discover. Make check or money order for full premium payable to Travel Insurance Services. All payments must be in U.S. dollars drawn on a U.S. bank. Do not send cash.

Mail payment and completed enrollment form to Travel Insurance Services, 2950 Camino Diablo, Suite 300, Walnut Creek, CA 94597-3991. Alternately, you may fax your enrollment to 610 537-9828. If faxing, please DO NOT mail the original enrollment form as this causes unnecessary duplication.

After you mail or fax your enrollment, Proof of Insurance will be sent by mail to your U.S. address on the enrollment form unless otherwise instructed. Correctly completed enrollments are processed and Confirmations of Insurance are normally mailed within 1-3 business days after receipt.

Monthly Premiums

Age	Plan A	Plan B
0 - 24	$39	$47
25 - 29	$42	$51
30 - 39	$47	$56
40 - 45	$73	$87
46 - 54	$82	$99
Spouse	$194	$233
Child	$64	$77

Optional Additional Emergency Medical Evacuation

Additional Limit	Rate
$100,000	Add $4 per month, per person
$250,000	Add $5 per month, per person

Premium Payment

You can enroll for up to twelve months at one time. You must pay premium in full for your enrollment period.

Refund of Premium

Premiums received by the Program Administrator will be considered fully earned and non-refundable. Coverage under this Program terminates if a Covered Person enters military service and a pro-rata refund will be made from the date written request is received. Otherwise, no refunds will be made.

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