Visit USA-HealthCare™ Enrollment Form | Official
Use Only: 0103/25M PC# 32701 Cert.# |
|
Plan Highlights
Please read the Visit USA-HealthCare Enrollment Details and Instructions before completing this enrollment. Note: Enrollment Form prints on 2 pages. |
| 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 | ________________________________ |
Arrival Date in USA (month/day/year) | ______/______/______ |
| 2. Requested Effective Date We request the coverage to begin on ______/______/______ (month/day/year) | |||
| 3. U.S. Mailing Address Send Insurance Certificate 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 AIG Life Trust 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, a member company of the American International Group of Companies (AIG). 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) | $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 | ||||
OPTIONAL:
Include your fax number: (_______) _______ - __________ for a rushed fax copy
of Certificate. Add $10 | $________ | ||||
Total
Payment Due | $________ | ||||
| 6. Enrollment
& Payment Please choose one method. (See Instructions for more details.) | Credit
Card Type (circle one) | ||
| ___ Enroll by Mail | Card # ________________________________ Exp. ____ / ____ | ||
| Card Holder Name ________________________________ | |||
| ___ Enroll
by Fax: Pay with credit card only | Billing Address___________________________________ | ||
|
| City, State, Zip___________________________________ | ||
| Signature ______________________________ Date ____ / ____ | |||
Visit USA-HealthCare Benefit Limits
| Benefits 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 |
$50,000 | $100,000 |
| Accidental Death & Dismemberment (AD&D) |
$50,000 | $100,000 |
| Repatriation of Remains | $10,000 |
$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: | |||||
| $250 |
$500 |
$1000 |
$250 |
$500 |
$1000 | |
| Under age 19 | $48 |
$43 | $38 |
$72 | $65 |
$58 |
| 19 - 29 | $50 |
$45 | $40 |
$76 | $68 |
$60 |
| 30 - 39 | $70 |
$63 | $56 |
$106 | $95 |
$85 |
| 40 - 49 | $97 | $87 | $78 | $146 | $132 | $117 |
| 50 - 59 | $137 |
$123 | $110 |
$207 | $186 |
$165 |
| 60 - 64 | $160 | $144 | $128 | $242 | $217 | $193 |
| 65 - 69 | $210 | $189 | $168 | $317 | $285 | $254 |
| 70 - 79 | $350 |
$315 | $280 |
N/A | N/A |
N/A |
| Age 80+ * | $450 |
$405 |
$360 |
N/A |
N/A |
N/A |
| * The Medical Expense Benefit Limit for ages 80+ is $10,000. | ||||||
| 15 Day Premiums | Plan
A | Plan B | ||||
| Age | Deductible Per Policy Period: | |||||
| $250 |
$500 |
$1000 |
$250 |
$500 |
$1000 | |
| Under age 19 | $27 |
$24 | $21 |
$40 | $36 |
$32 |
| 19 - 29 | $28 |
$25 | $22 |
$42 | $38 |
$33 |
| 30 - 39 | $39 |
$35 | $31 |
$59 | $53 |
$47 |
| 40 - 49 | $54 | $48 | $43 | $81 | $73 | $65 |
| 50 - 59 | $76 |
$68 | $61 |
$114 | $103 |
$91 |
| 60 - 64 | $88 | $80 | $71 | $134 | $120 | $107 |
| 65 - 69 | $116 | $104 | $93 | $175 | $157 | $140 |
| 70 - 79 | $193 |
$174 | $154 |
N/A | N/A |
N/A |
| Age 80+ * | $248 |
$223 |
$198 |
N/A |
N/A |
N/A |
| * 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
To top of page
| Eligibility Effective Date
Expiration Date
To top of page 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 Certificates of Insurance are normally mailed within 1-3 business days after receipt. To top of page |