Brochure Request Form

Active Brokers may fill out this form to request a supply of brochures/enrollment forms. Your supplies will be shipped to you via U.S. mail or UPS.

Please enter the brochure quantity for each plan below.

InterMedical Insurance®
Study USA-HealthCare®
Visit USA-HealthCare®
WorldMed Insurance®
Worldwide Group Protector®
Voyager Annual Insurance

Broker Promotional Tools Agreement

By submitting this form, I agree to use the above requested promotional materials as is, with no changes to the text or layout, with the exception of adding my name, my agency name (and/or logo), license number, address, phone number, fax number and/or email address.