Inbound USA 2004 - Visitor Medical Insurance from SRI

[ ] Check

[ ] Money Order

[ ] MasterCard

[ ] Visa

[ ] Discover

Card Number:

Expiration Date:

Daytime Phone:

Name on Card:

Billing Address

Signature (Required):

Make Check or Money Order payable to "SRI". Total payment for the Full Term of coverage requested must be paid in U.S. dollars at the time application for coverage is made. Coverage purchased by credit card is subject to validation and acceptance by the credit card company.

I declare that I agree and I agree to read and understand the terms and conditions of this product as outlined in this brochure and the program summary, including coverage is not available to any U.S. citizen. I understand that pre-existing conditions, as defined in this brochure, are not covered. I understand that this is not a general health insurance product, but a limited benefit program designed to provide basic benefits under certain circumstances. I also understand that Lloyd's operates as an approved but non-admitted insurer in most US states and that claims may not be made against any state guarantee fund. I understand and agree that this program does not comply with any US state insurance law. I also understand any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an enrollment form, or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

I hereby subscribe to the Global International Trust and enroll in the group coverage for which I am eligible under the group contract issued by Certain Underwriters at Lloyd's, London. As signatory, I declare that I am affirming all statements for all persons listed on the application (and declare that I have the authority to do so).

____________________________________________________
Signature of Insured or Proxy (Required) ......... Date Signed

Inbound USA, Copyright 2004, Specialty Risk International, Inc.(SRI)
"Inbound" is a registered trademark of Specialty Risk International, Inc.

Inbound USA Application - 2004
Official Use Only:	Cert#	Processed:	Eff. Date:	Agent:1608
Effective January 1, 2004
All sections must be completed. Incomplete applications will be returned to the applicant without coverage.

Last Name:
First Name:
U.S. Correspondence Address:
Name:
Address:
City:	State:
Postal Code:	Country: USA
Daytime Phone Number: ( _____ )	Email:
AD&D Beneficiary:	Relationship:

Passport Number:
Country Issuing Passport:
When did or will you arrive in the United States? (MM/DD/YY) ____ / ____ / ____
When would you like coverage to begin? (MM/DD/YY) ____ / ____ / ____
Note: This program is not available to United States Citizens. Your coverage must begin within twelve (12) months of your arrival in the United States. The minimum period of coverage is 1 month, maximum is 12. If 3 months or more of premium is sent, an automatic renewal notice will be sent to the address above. Total program length available is 36 months. Coverage cannot begin until you depart from your Home Country and SRI both receives and accepts your application and correct premium.

Have you purchased insurance through SRI before? [ ] Yes [ ] No	If Yes, ID Number:
Selected Medical Policy Maximum: [ ] Plan A - $50,000 [ ] Plan B - $100,000
Selected Per Injury / Sickness Deductible: [ ] $75 or [ ] $150 (70 and over is $250)

Name of Persons to be Insured:	Date of Birth MM/DD/YY	Monthly Premium
Applicant:
Spouse:
Child:
Child:
Child:
Total: [A]
Multiply by number of months	X
Total:		$
Administrative Fee (required)	+	$7.00
Total Payment Enclosed:		$