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It's easy. Just print and complete the following
application or go to online
quotes and applications
Mail the completed form, along with your payment, to:
Insurance Services of
America
1757. E. Baseline Road, Suite 126
Gilbert, AZ 85233
If paying by credit card, you may fax your application to
480.821.9297
or E-mail it to health@missionaryhealth.net
APPLICATION:
Please Print your Name (as you would like it to
appear on your ID card):
| (Last) |
(First) |
(Middle) |
| Passport #: |
| Send Certificate of Insurance to:
(if different than above) |
| Name: |
| Address: |
| Telephone: |
Fax: |
| Requested Effective Date: |
Date of Departure: |
| Date of Return to Home Country: |
Country of Citizenship: |
| Countries to be visited: |
Name of Beneficiary:
(Note: You will be the Beneficiary for spouse and dependent
children included on this Application.) |
HOW DO I CALCULATE MY PREMIUM?
Follow these instructions:
| 1. Select One Plan and One Option: |
|
| ATLAS INTERNATIONAL |
Option #1 |
Option #2 |
Option #3 |
Option #4 |
| ATLAS AMERICA |
Option #5 |
Option #6 |
Option #7 |
| ATLAS EXTRA |
Option #8 |
Option #9 |
Option #10 |
Option #11 |
2. List the names of individuals to be covered, and
the appropriate premium for the Plan and Option selected:
| Name |
Date of Birth |
Monthly Premium |
15 day Premium |
| Applicant: |
|
|
|
| Spouse: |
|
|
|
| Child: |
|
|
|
| Child: |
|
|
|
| Child: |
|
|
|
| Subtotal: |
A. $ |
B. $ |
3. Complete the following:
A.$ __________
(from above) |
X |
__________
(number of months) |
= |
C.$ __________ |
| C.$ __________ |
+ |
B.$ __________
(from above) |
= |
D.$ __________ |
| D.$ __________ |
X |
__________
(Deductible Factor) |
= |
F.$ __________ |
F.$ __________
(Optional Hazardous
Sports Rider) |
X |
1.20 |
= |
G.$ __________ |
G.$ __________
(Incidental Home
Country Rider*) |
X |
1.10 |
= |
H.$ __________ |
| H.$ __________ |
+ |
$ 15.00
(optional overnight charge to U.S. Address) |
= |
I.$ __________ |
| I.$ __________ |
+ |
$ 25.00
(optional overnight charge to Non-U.S. Address) |
= |
J.$ __________ |
| J.$ __________ |
+ |
$ 5.00
(Non-refundable Policy Fee) |
= |
K.$ __________
TOTAL PAYMENT |
* Optional and Available only when purchasing a minimum of 3
months.
| All Products - Deductible Factors
| $100 - 1.10 |
$250 - 1.00 |
$500 - .95 |
$1000 - .85 |
$2500 - .75 |
|
| 4. If you are purchasing the Hazardous Sports
Rider, please describe the activities for which you are seeking
coverage:
|
5. Complete the following:
| Payment Mode: |
Check/Money Order |
MasterCard |
| Visa |
American Express |
| Credit Card #: |
Expiration Date: |
| Name as it appears on card: |
| Signature: |
Daytime Phone #: |
| Billing Address:
|
| Check or Money Orders should be
made payable, in US dollars, to MultiNational Underwriters, Inc.
If paying by credit card, I authorize MultiNational
Underwriters, Inc. to debit my VISA, MasterCard or American
Express account for the amount specified in H. above. Coverage
purchased by credit card is subject to validation and acceptance
by the credit card company. |
6. Read and sign below.
| I hereby apply for membership in the
Atlas/International Citizen Group Insurance Trust, for the
insurance provided to members by Lloyd's. I understand that this
is not a general health insurance policy and that it is intended
for use in the event of a sudden and unexpected event while I am
traveling outside of my Home Country. I understand that
Pre-existing Conditions are not covered. I understand this
insurance contains a Pre-certification Penalty, and other
restrictions and exclusions. I understand this insurance is not
renewable and successive periods of insurance will require
re-satisfaction of the Deductible and Coinsurance. I understand
that the information contained herein is a summary of the Master
Policy, and that I may obtain a complete copy of the Master
Policy upon request. I understand that Lloyd's operates as an
approved but non-admitted insurer in all states of the United
States except Illinois and Kentucky where they are admitted. As
such, claims under this insurance may not be made against any
state guaranty fund. If signed by an agent of the Applicant, the
undersigned warrants his/her capacity to so act. By acceptance
of coverage, the Applicant ratifies the authority of the
signatory to bind him/her. The undersigned authorizes any
doctor, medical practitioner, hospital, clinic, health facility,
pharmacy, government agency, insurance agency, insurance
company, group policyholder or insurance or benefit
administrator or any other entity having information as to the
care, advice, treatment, diagnosis or physical or mental
condition of any person listed on this Application to release
said information to MultiNational Underwriters, Inc. |
Signature of Applicant (or
Guardian):_______________________ Date:__________
Signature of Spouse:_______________________
Date:__________
|
7. For Agent Use Only:
| Producer Number: 23600 |
Producer Name: |
| Company Name: Insurance Services of America |
Mailing Address: 1757. E. Baseline Road, Suite 126 |
| City: Gilbert |
State: AZ |
Postal Code 85233 |
| Country: USA |
Telephone: 800-647-4589 |
Fax: 480-821-9297 |
| E-mail Address: health@missionaryhealth.net |
Signature: |
Insurance Services of America
1757. E. Baseline Road, Suite 126, Gilbert, AZ 85233
800-647-4589 / 480-821-9297 (fax)
480-821-9052 (worldwide)
Email: health@missionaryhealth.net
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