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, 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. 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
(364 days Max.)
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:
$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:
$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

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:

  1. the departure of the Insured Person from his home country for his trip to the United States;
  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 from his trip to the United States,
  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 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, 3070 Riverside Drive, Columbus, OH 43221, USA. 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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