Visit USA-HealthCare Enrollment Form Official Use Only:
0301/50M
PC#
Cert.#
Plan HighlightsOutline of Coverages Rates
Please read the Visit USA-HealthCare™ Enrollment Details and Instructions before completing this enrollment. Note: Enrollment Form prints on 2 pages.
1. Visitor Information    
Insured Last Name
 ________________________________    
First Name, Middle Initial
 __________________________, ____
Arrival Date in USA (mm/dd/yy)
 ______/______/______
Home Country Address
 ________________________________
Passport #
 ________________________________
________________________________
Country of Issue
 ________________________________
City
 ________________________________
Beneficiary
 ________________________________
Postal Code, Country
 ________________________________ (You will be the beneficiary for your insured spouse and children.)
 
2. Requested Effective Date We request Visit USA-HealthCare™ to begin on ______/______/______ (mm/dd/yy)
 
3. U.S. Mailing Address Send Insurance Certificate to this U.S. address, in care of U.S. Resident:
c/o Name
 ________________________________
Address
 ________________________________
Daytime Phone
 (______) _______________
City, State, Zip Code
 ________________________________
 
4. Enrollment Agreement
I hereby subscribe to the AIG Life Trust and enroll in the group coverage for which I am eligible under the group contract issued by The Insurance Company of the State of Pennsylvania, a member company of the American International Group of Companies (AIG). The Insured(s) understand(s) that this insurance will not pay benefits for any expenses incurred caused by any pre-existing condition (refer to Exclusions). All claims will be fully investigated. Refund of premium, less a $20 processing fee, will be returned only if a written request is received by Travel Insurance Services prior to the effective date of coverage. After the effective date of coverage, the premium is considered fully earned and non-refundable.
Signature of Insured or Proxy____________________________ Date _____/_____/_____ (mm/dd/yy)

5. Calculating Your Premium

5a. Basic Plan
Choose Plan: (circle one)
Plan A
Plan B
Choose Deductible: (circle one)
$100
$500
$1,000
           
Visitor's Name
Date of Birth (mm/dd/yyyy)
Monthly Premium
# of Months
15-Day Premium
(if applicable)
Total
____________________
__/__/_____
$______
x____
$______
=$______
Insured
          
____________________
__/__/_____
$______
x____
$______
=$______
Spouse
          
____________________
__/__/_____
$______
x____
$______
=$______
Child
          
____________________
__/__/_____
$______
x____
$______
=$______
Child
Total Basic Plan $ ________
5b. Optional Additional AD&D
Purchase same # of months as Basic Plan.
       
Monthly Premium
#of Months
15-Day Premium
(if applicable)
Total
$______
x____
$______
=$______
       
$______
x____
$______
=$______
       
$______
x____
$______
=$______
       
$______
x____
$______
=$______
Optional Additional AD&D $________
5c. Total Premium Due  
Total Basic Plan (5a)
Add Enrollment Fee
Total Optional AD&D (5b)
Total Due to Travel Insurance Services
$_________
+ $5.00
+ $ _________
= $ _________

 

Visit USA-HealthCare™ Benefit Limits

Benefits Included
Plan A Limit
Plan B Limit
Illness and Injury Medical Expense/Incident*
* The Medical Expense Benefit Limit for ages 80+ is $10,000.
$50,000
$100,000
Emergency Medical Evacuation
$50,000
$100,000
Accidental Death & Dismemberment (AD&D)
$50,000
$100,000
Repatriation of Remains
$10,000
$20,000
Family Travel Benefit
$10,000
$10,000
Incidental Travel (to Canada, Mexico, U.S. Territories, maximum 14 days)
Included
Included
Emergency Travelers Assistance Service
Included
Included
Optional Additional AD&D
Limit
Limit
Flight Insurance
$250,000
AD&D Due to Other Accidents
$100,000

Premium Per Insured Person Rate Charts

Monthly Premiums
Plan A
Plan B
Age Deductible Per Policy Period:
$100
$500
$1000
$100
$500
$1000
Under age 19
$50
$34
$24
$76
$52
$35
19 - 29
$86
$59
$42
$132
$91
$63
30 - 49
$142
$97
$69
$215
$148
$104
50 - 69
$203
$140
$98
$307
$210
$147
70 - 79
$267
$196
$176
N/A
N/A
N/A
Age 80+ *
$388
$284
$256
N/A
N/A
N/A
* The Medical Expense Benefit Limit for ages 80+ is $10,000.

 

Optional Additional AD&D Rates    
Premium (all ages) $30 / month $15 / 15 days

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Enrollment Details

Eligibility
Apply early to begin coverage when you leave your home country. Coverage is available to international visitors who come to the U.S. for pleasure, business or study and to new immigrants to the U.S.

Effective Date
Coverage begins at 12:01 a.m. on the latest of:

  1. the departure of the Insured Person from his home country for his trip to the United States;
  2. the date after the Insured Person's completed enrollment form and correct premium are postmarked to Travel Insurance Services; or
  3. the requested effective date on the enrollment form.

Expiration Date
Coverage will terminate on the earliest of:

  1. the return of the Insured Person to his home country from his trip to the United States,
  2. twelve (12) months after the effective date of coverage; or
  3. the requested termination date on the Insured Person's enrollment form for which premium has been paid.

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Instructions

Read the Brief Outline of Coverages.

Print this Enrollment Form and complete the hard copy (items 1-5) for you, your spouse, and your children (age 14 days through 18 years). Incomplete forms will not be processed and will be returned.

Make check or money order for full premium payable to Travel Insurance Services. All payments must be in U.S. dollars drawn on a U.S. bank. Do not send cash.

Mail payment and completed enrollment form to Travel Insurance Services, 2950 Camino Diablo, Suite 300, Walnut Creek, CA 94597-3991.

Or if you prefer, you may fax your completed enrollment form and check as payment via "check-by-fax" to 925-932-0442. If you use this method of enrolling, please follow these guidelines:

  1. Write out your check as you normally would.
  2. Write "check-by-fax" in the memo of your check.
  3. Make a clear photocopy of your check on white paper (to make faxing easier).
  4. Rewrite the Fraction code on the photocopy above the check, as these small numbers are difficult to read on a fax. The Fraction code is the tiny set of numbers printed near the check number.
  5. Be sure that the Routing and Checking account numbers are legible. (These are the long series of numbers at the bottom of the check.) If they are not, you may rewrite near the original numbers on the photocopy.
  6. Fax check and completed enrollment form to 925-932-0442.
  7. Do not mail your enrollment and check after faxing, as this causes unnecessary duplication.

To ensure no gap in coverage, a second Enrollment Form must be postmarked no later than the day the previous policy expires.

Proof of Insurance

Proof of insurance will be sent by mail to your U.S. address on the Enrollment Form unless otherwise instructed. Correctly completed enrollments are processed and Certificates of Insurance are normally mailed within 1-3 business days after receipt.

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