Study USA-HealthCare™ Enrollment Form - PREFERRED 9498713 - Inbound / 9498714 - Outbound	Official Use Only:09/11 Conf.# PC# 240466 Eff Date: ___/___/___ Date Rec'd: ___/___/___
Please read the Study USA-HealthCare 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.

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 at a U.S. school
Country	________________________________________	I am a student studying outside the U.S. and registered at a U.S. school
Phone	________________________________________	I am a student studying outside the U.S., but not registered at a U.S. school
		Name of school, college or university	________________________________________
		Your school is located in which state	________________________________________
2. Enrollment Type		3. Payment Choose one method. (See instructions below for details.)
	First Time Enrollment	Enroll by Mail Payment: check credit card
	Dependent Enrollment Only	Enroll by Fax: Pay with credit card or check only (DO NOT mail originals.)
	Confirmation Number ______________________	Credit Card Type Visa MasterCard Discover
	Renewal for Self/Dependents	Card # ________________________________ Exp. ____ / ____
	Confirmation Number ______________________	Card Security Code # _____________
		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	Total Monthly Premium	# of Months (max.12)	Total Payment
Name - Complete the form below for yourself and any dependents you are enrolling.
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
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

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 Premium

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.