Visit USA-HealthCare Printable Enrollment Form

Visit USA-HealthCare™ Enrollment Form	Official Use Only: 0103/25M PC# 32701 Cert.#
Plan Highlights Outline of Coverages Rates FAQs Please read the Visit USA-HealthCare™ Enrollment Details and Instructions before completing this enrollment. This plan is currently not available to insureds that reside in Idaho or Washington and/or insureds traveling from outside the U.S. to Idaho or Washington. Please call us at 1-800-937-1387 to learn about other plans that may be available.

1. Visitor Information
Insured Last Name	________________________________
First Name, Middle Initial	__________________________, ____	Passport #	________________________________
Home Country Address	________________________________	Country of Citizenship	________________________________
	________________________________	Beneficiary	________________________________
City	________________________________	(You will be the beneficiary for your insured spouse and children.)
Postal Code, Country	________________________________

2. Requested Effective Date We request the coverage to begin on ______/______/______ (month/day/year)

3. U.S. Mailing Address Send Insurance Confirmation to this U.S. address, in care of U.S. Resident:
c/o Name	________________________________	Address	________________________________
Daytime Phone	(______) _______________	City, State, Zip Code	________________________________

4. Enrollment Agreement
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. The Insured(s) understand(s) that this insurance will not pay benefits for any medical expenses caused by any pre-existing condition (refer to Exclusions). All claims will be fully investigated. 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)

5. Calculating Your Premium

Basic Plan	Choose Plan (circle one)		Plan A ($50,000)	Plan B ($100,000)
	Choose Deductible (circle one)	$50	$250	$500	$1,000

	Date of Birth (mo/day/yr)	Monthly Premium	# Months	15 Day Premium
__________________ Insured	___/___/_____	$________	x ______	+ $________ =	$________
__________________ Spouse	___/___/_____	$________	x ______	+ $________ =	$________
__________________ Child 14 days - 18 yrs)	___/___/_____	$________	x ______	+ $________ =	$________
__________________ Child (14 days - 18 yrs)	___/___/_____	$________	x ______	+ $________ =	$________
				Subtotal	$________
Optional Benefits	___ Add Additional AD&D Coverage ___ Add Hazardous Activity Coverage		ONE Option, Multiply by 1.20 BOTH Options, Multiply by 1.30		x________
			Total Premium		$________
			Enrollment Fee		+ 5.00
			Total Payment Due		$________

6. Enrollment & Payment Please choose one method. (See Instructions for more details.)
___ Enroll by Mail			Credit Card Type circle one)VisaMasterCardDiscover

Payment:___check___credit card			Card # _______________________________ Exp. ____ /____
___ Enroll by Fax: Pay with credit card or check			Card Security Code # _____________
Fax to: (610) 537-9825 (DO NOT mail originals.)			Card Holder Name ________________________________
			Billing Address___________________________________
			City, State, Zip___________________________________
			Signature ____________________________ Date ____ /____

Visit USA-HealthCare™ Benefit Limits

Benefits and Services Included	Plan A Limit	Plan B Limit
Illness and Injury Medical Expense/Incident* * The Medical Expense Benefit Limit for ages 80+ is $10,000.	$50,000	$100,000
Emergency Medical Evacuation	$75,000	$150,000
Accidental Death & Dismemberment (AD&D)	$50,000	$100,000
Repatriation of Remains	$20,000	$20,000
Family Travel Benefit	$10,000	$10,000
Incidental Travel (to Canada, Mexico, U.S. Territories, maximum 14 days)	Included	Included
Emergency Travelers Assistance Service	Included	Included
Optional Benefits
Additional AD&D Flight Insurance AD&D Due to Other Accidents	$250,000 $100,000
Hazardous Activity Coverage	Medical Expense coverage for activities normally excluded from coverage such as motorcycling, scuba diving, skiing and whitewater rafting.

Premium Per Insured Person Rate Charts

Monthly Premiums	Plan A				Plan B
Age	*Deductible Per Policy Period:**
Age	$50	$250	$500	$1000	$50	$250	$500	$1000
Under 6	$225	$180	$162	$144	$315	$252	$227	$202
6 - 18	$48	$38	$34	$30	$67	$53	$48	$43
19 - 29	$50	$40	$36	$32	$70	$56	$50	$45
30 - 39	$66	$53	$48	$42	$93	$74	$67	$59
40 - 49	$101	$81	$73	$65	$142	$113	$102	$91
50 - 59	$171	$137	$123	$110	$240	$192	$173	$153
60 - 64	$200	$160	$144	$128	$280	$224	$202	$179
65 - 69	$325	$260	$234	$208	$455	$364	$328	$291
70 - 79	$547	$438	$394	$350	N/A	N/A	N/A	N/A
80+ *†	$563	$450	$405	$360	N/A	N/A	N/A	N/A
* There is a $250 Emergency Room Deductible which will be waived if admitted to the hospital. † The Medical Expense Benefit Limit for ages 80+ is $10,000.

15 Day Premiums	Plan A				Plan B
Age	*Deductible Per Policy Period:**
Age	$50	$250	$500	$1000	$50	$250	$500	$1000
Under 6	$93	$74	$67	$59	$130	$104	$94	$83
6 - 18	$27	$21	$19	$17	$37	$30	$27	$24
19 - 29	$28	$22	$20	$18	$39	$31	$28	$25
30 - 39	$37	$30	$27	$24	$52	$41	$37	$33
40 - 49	$57	$45	$41	$36	$79	$64	$57	$51
50 - 59	$95	$76	$68	$61	$133	$106	$96	$85
60 - 64	$110	$88	$79	$70	$154	$123	$111	$99
65 - 69	$210	$168	$151	$135	$294	$235	$212	$188
70 - 79	$302	$241	$217	$193	N/A	N/A	N/A	N/A
80+ *†	$310	$248	$223	$198	N/A	N/A	N/A	N/A
* There is a $250 Emergency Room Deductible which will be waived if admitted to the hospital. † The Medical Expense Benefit Limit for ages 80+ is $10,000.

Optional Benefits Rates

Additional Accidental Death & Dismemberment Coverage
Hazardous Activity Coverage

This will increase your Basic Plan Premium as follows:

Add ONE Optional Benefit - Multiply Basic Plan Premium by 1.20
Add TWO Optional Benefits - Multiply Basic Plan Premium by 1.30

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Enrollment Details

Eligibility
Apply early to begin coverage when you leave your home country. Coverage is available to international visitors who come to the U.S. for pleasure, business or study and to new immigrants to the U.S.

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

the departure of the Insured Person from his home country for his trip to the United States;
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 from his trip to the United States,
twelve (12) months 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 the Brief Outline of Coverages.

Print this enrollment form and complete the hard copy (items 1-6) for you, your spouse, and your children (under age 19). 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, when paying by credit card, you may fax your enrollment to (610) 537-9825. If faxing, please DO NOT mail the original enrollment form as this causes unnecessary duplication.

To ensure no gap in coverage, a second Enrollment Form must be postmarked no later than the day the previous policy expires.

Proof of Insurance

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.

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Visit USA-HealthCare™ Enrollment Form