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International Injury and Illness Insurance

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BIOGRAPHICAL INFORMATION

First Name:
Last Name:
Date of Birth:	(mm/dd/yyyy)
Gender:
Mailing Address:	Apt:
City:
State/Zip Code: (in U.S.):	/
Province/Postal Code (not in U.S.):	/
Country:
Telephone Number:
Email:

INSURANCE COVERAGE INFORMATION

College/University Attending:

Coverage Start Date:

Coverage Period:

Continues for whole months.
(Any fraction of a month must be calculated as a whole month.)

	Monthly Rates	No. of Months	Total Premium
International Participant:	$86.00	X	= $
Spouse:	$215.00	X	= $
Each Child:	$108.00 X (No. of Children)	X	= $
Total Premium Submitted:			$

* Dependent To Be Insured - Dependent coverage is only available if the participant enrolls in this insurance program.

	First Name/Middle Initial	Last Name	Gender	Date of Birth
Spouse:
Child #1:
Child #2:
Child #3:

APPLICANT NOTICE - By accepting this disclaimer, acknowledgement is made that; 1) you meet the eligibility requirements; 2) if at any time it is determined you did not meet the eligibility requirements for this coverage, the only liability the Company has is the refund of premium, subject to any claims for which benefits has been paid prior to discovery of the ineligibility; 3) the Company assumes no responsibility for notification to the insured prior to or at the termination of coverage for any insured period.

Yes. By accepting this, I certify to the eligibility for insurance of the individuals named hereon.

METHOD OF PAYMENT

Total Amount Charged ($):

Credit Card Type:
Credit Card Number:
Expiration Date:
Billing Option:	Yes, the billing address is same as mailing address No, I want to use a different address
First Name on the Card:
Last Name on the Card:
Billing Address:
Billing City:
Billing State / Zip Code:	(required if in U.S.)
Billing Country: