Study USA-HealthCare™ Enrollment Form
OFFICE USE ONLY
Cert. # _____________________
Eff. Date ______/______/______
2. Enrollment Type
First Time Enrollment
0304/20M
132876
PC # ____________________
Rec’d ______/______/______
For Myself
For Myself and Dependents
Dependent Enrollment
1. Insured’s Information
My Certificate I.D. is
Last Name
Renewal for Self/Dependents
First Name
My Certificate I.D. is
Plan Requested
Mailing Address
Plan A
Plan B
Months of Coverage (maximum 12 months)
Requested Effective Date (month/day/year)
City
State/Province, Zip/Postal Code
3. Payment
Phone
Check or Money Order, payable to Travel Insurance Services.
Email Address
Must be U.S. dollars drawn on a U.S. bank.
Passport Number
Visa
MasterCard
Country Issuing Passport
Card Number
Visa Type
Expiration Date
I am a foreign student currently registered in a U.S. school.
I am a U.S. registered student studying abroad.
Discover
Card Holder Name
Billing Address
Name of School, College, or University
City, State, Zip
Signature
4. Rate Calculation
Name - Complete the form below for yourself and any dependents
are enrolling.
you
Date of Birth
(month/day/year)
Arrival Date in
Country of Study
(month/day/year)
Insured
/
/
/
/
Spouse
/
/
/
/
Dependent
/
/
/
/
Dependent
/
/
/
/
+
I hereby enroll in Study USA-HealthCare™. All claims will be fully investigated. Premiums received by the Program Marketer/Insurance
Company will be considered fully earned and non-refundable. Coverage under this program terminates if a covered Person enters military service
and a pro-rata refund will be made from the date a written request is received. Otherwise, no refunds will be made.
Signature of Insured or Proxy
Date
/
Total
Monthly
Premium
Monthly Add’l Medical
Premium Evacuation
(if applicable)
/
=
Total
Payment
Number
of Months
(max. 12 )
=
x
Subtotal
=
Administration Fee
+
TOTAL PAYMENT DUE
=
5.00