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Rates:
Valid through 7/31/2005
Displayed Rates are for $250 Deductible Option (in USD)
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Day Tripper Group
International US Citizens Traveling Abroad
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Maximum
Limit
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$50,000
|
$100,000
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$250,000
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$500,000
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$1,000,000
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AGE
|
Monthly
|
Daily
|
Monthly
|
Daily
|
Monthly
|
Daily
|
Monthly
|
Daily
|
Monthly
|
Daily
|
|
18-29
|
31.00
|
1.00
|
37.00
|
1.20
|
38.00
|
1.30
|
40.00
|
1.35
|
44.00
|
1.50
|
|
30-39
|
37.00
|
1.20
|
43.00
|
1.40
|
50.00
|
1.70
|
53.00
|
1.80
|
58.00
|
1.90
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|
40-49
|
59.00
|
2.00
|
66.00
|
2.20
|
67.00
|
2.25
|
68.00
|
2.30
|
75.00
|
2.50
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|
50-59
|
97.00
|
3.20
|
111.00
|
3.70
|
112.00
|
3.70
|
113.00
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3.80
|
126.00
|
4.20
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|
60-64
|
122.00
|
4.10
|
132.00
|
4.40
|
158.00
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5.20
|
172.00
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5.70
|
191.00
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6.40
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65-69
|
152.00
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5.10
|
167.00
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5.60
|
178.00
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5.90
|
185.00
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6.20
|
204.00
|
6.80
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70-79
|
204.00
|
6.80
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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80+*
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463.00
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15.40
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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Dep. Child
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19.00
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0.60
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23.00
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0.80
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24.00
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0.80
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25.00
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0.80
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26.00
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0.90
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Child Alone
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31.00
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1.00
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35.00
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1.20
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37.00
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1.30
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38.00
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1.30
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42.00
|
1.40
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*10,000 Maximum Limit
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Day Tripper Group
America Non-US Citizens Traveling Outside of Home Country
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|
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Maximum
Limit
|
$50,000
|
$100,000
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$250,000
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$500,000
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$1,000,000
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AGE
|
Monthly
|
Daily
|
Monthly
|
Daily
|
Monthly
|
Daily
|
Monthly
|
Daily
|
Monthly
|
Daily
|
|
18-29
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43.00
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1.40
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50.00
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1.70
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58.00
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1.90
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62.00
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2.10
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73.00
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2.40
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30-39
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55.00
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1.80
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66.00
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2.20
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76.00
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2.50
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82.00
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2.70
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95.00
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3.20
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40-49
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84.00
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2.80
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95.00
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3.20
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110.00
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3.70
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123.00
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4.10
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139.00
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4.60
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50-59
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120.00
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4.00
|
146.00
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4.90
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160.00
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5.40
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174.00
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5.80
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200.00
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6.70
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60-64
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141.00
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4.70
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193.00
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6.40
|
210.00
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7.00
|
224.00
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7.50
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250.00
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8.30
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65-69
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179.00
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6.00
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223.00
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7.40
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255.00
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8.50
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271.00
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9.00
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293.00
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9.80
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70-79
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227.00
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7.60
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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80+*
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446.00
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14.90
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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N/A
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Dep.
Child
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25.00
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0.80
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29.00
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1.00
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32.00
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1.10
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34.00
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1.10
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38.00
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1.30
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Child
Alone
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39.00
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1.30
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46.00
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1.50
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51.00
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1.70
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54.00
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1.80
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64.00
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2.10
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*$10,000 Maximum Limit
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Deductible Factor Table
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Hazardous
Sports Rider Factor: 1.20
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DEDUCTIBLE:
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FACTOR:
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$
0
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1.5
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PREMIUMS ARE NON-REFUNDABLE
AFTER YOUR EFFECTIVE DATE.
IF REQUESTING CANCELLATION, YOU MUST NOTIFY HCCI, IN
WRITING, PRIOR TO THE EFFECTIVE DATE FOR A FULL REFUND.
OVERNIGHT CHARGES ARE NOT REFUNDABLE.
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$100
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1.1
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$250
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1.0
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$500
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0.9
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$1,000
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0.8
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$2,500
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0.7
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DAY
TRIPPER GROUP APPLICATION
MultiNational Underwriters, Inc.
Lloyd's Coverholder
Print all Names as you would like them to appear on your Identification Cards.
Please print clearly and provide complete information.
| Name
of Sponsoring Organization:
|
Contact
Name:
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| COMPLETE
Mailing Address for all correspondence:
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Telephone
#:
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Fax
#:
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E-mail
Address:
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Destination:
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Purpose
of Trip:
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Names
of all
individuals
to be covered
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Deductible:
$ |
Maximum
Benefit: $
|
| Name
(Last, First) |
Birth
Date
mm/dd/yy |
Country
of
Citizenship |
Effective
Date
mm/dd/yy |
#
of Days |
x |
Daily
Rate |
= |
Subtotal |
1.
|
|
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|
x |
|
= |
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2.
| |
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|
x |
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= |
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3.
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|
x |
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= |
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4.
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|
x |
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= |
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5.
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x |
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= |
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| 6. |
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x |
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= |
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| 7. |
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x |
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= |
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| 8. |
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x |
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= |
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Group
Subtotal Total from above and from additional census (if any)
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Multiply
Deductible Factor from Deductible Factor Table
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Enter
Factor for Hazardous Sports Rider, if Selected (1.2). Otherwise Enter
1.0
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Total
Amount Due
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Payment Information
Payment
Mode:
Check/Money Order:
Discover Card
MasterCard
VISA
American Express
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Credit
Card #:
Expiration
Date
(mm/yy):
|
| Name
as it appears on card:
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COMPLETE
Billing Address:
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| Daytime
Phone #:
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Signature:
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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 Discover, VISA, MasterCard or American Express account for the
amount specified above. Coverage
purchased by credit card is subject to validation and acceptance by the
credit card company. Total
payment for the initial term of coverage requested must be entirely paid
in U.S. dollars at time of Application or prior to the Effective Date of
Coverage.
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The Sponsoring Organization (Sponsor), on behalf of and as authorized
agent and proxy for each of the group participants listed on the
Application, hereby applies for membership in the Atlas/International
Citizen Group Insurance Trust,
Hamilton
,
Bermuda
, and for the insurance
provided to members by Lloyds. The
Sponsor and all group participants understand that the insurance applied
for is not a general health insurance policy, but is intended for use by
members in the event of a sudden and unexpected event while traveling
outside their Home Country(ies). The
Sponsor and all group participants understand this insurance contains a
Pre-existing Condition exclusion, a Pre-notification Penalty and other
restrictions and exclusions. The
Sponsor and all group participants understand that coverage under this
insurance is not renewable and successive periods of insurance will
require re-satisfaction of the Deductible, Coinsurance, Pre-existing
Condition provision, and all other conditions of the insurance following
acceptance of a new Application.
The Sponsor and all group participants understand that the
information contained herein is a summary of the Master Policy and that
they may obtain a complete copy of the Master Policy upon request to
MultiNational Underwriters, Inc. The
Sponsor and all group participants understand that Lloyds, as
underwriter of the plan, is solely liable for the coverage and benefits
provided under the insurance. The
Sponsor and all group participants understand that Lloyds operates as
an approved, 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. The
Sponsor and all group participants understand and agree that the
insurance agent/broker, if any, assisting with this Application is their
representative. If signed
by a representative of the Sponsor, the undersigned warrants his/her
capacity to so act. If
signed as Sponsor, the undersigned warrants his/her authority to so act.
By acceptance of coverage and/or submission of any claim for
benefits, the each group participant ratifies the authority of the
signer to so act and bind the group participant. |
| Signature
of Sponsor:
|
Date
of Signature:
|
For Producer Use Only
| Producer
ID Number: 23600
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Producer
Name: ISA
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| Company
Name:
|
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| Street
Address:
|
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| City:
|
State:
|
Country:
|
Postal
Code:
|
| Telephone:
|
Fax:
|
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| Signature:
|
E-Mail
Address:
|
Please
fax enrollment form to: 480-821-9297 or mail with check to:
Insurance
Services of
America
1757. E. Baseline Road, Suite 126
Gilbert
,
AZ
85233
Administered by MultiNational Underwriters, Inc.
a TRAVEL GUARD International company
Additional Names of Group Members
| Name
(Last, First) |
Birth
Date
mm/dd/yy |
Country
of
Citizenship |
Effective
Date
mm/dd/yy |
#
of Days |
x |
Daily
Rate |
= |
Subtotal |
9.
|
|
|
|
|
x |
|
= |
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10.
| |
|
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|
x |
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= |
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11.
|
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|
x |
|
= |
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12.
|
|
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|
x |
|
= |
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| 13.
|
|
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|
|
x |
|
= |
|
| 14.
|
|
|
|
|
x |
|
= |
|
| 15.
|
|
|
|
|
x |
|
= |
|
| 16
|
|
|
|
|
x |
|
= |
|
17.
|
|
|
|
|
x |
|
= |
|
| 18. |
|
|
|
|
x |
|
= |
|
| 19. |
|
|
|
|
x |
|
= |
|
| 20. |
|
|
|
|
x |
|
= |
|
Please fax enrollment form to: 480-821-9297 or mail
with check to:
Insurance
Services of
America
1757. E. Baseline Road, Suite 126
Gilbert
,
AZ
85233
Administered by MultiNational Underwriters, Inc.
a TRAVEL GUARD International company
|
