Applicant Information Last Name: _________________________________________ First Name: _______________________________ M.I.______ Country of Permanent, fixed Residence (Home Country) __________ Passport Number / Country: ____________________________ Departure Date from your Home Country? (MM/DD/YY) ____/____/____ AD&D Beneficiary: _____________ Relationship: ___________ (Accidental Death & Dismemberment) Address of Correspondence (where ID card is to be sent) Name: _____________________________________________ Address: ___________________________________________ City: _______________________________ State: __________ Postal Code: _____________ Country: __________________ Work Phone: ( ) __________ Home Phone: ( ) ____________ Email: ______________________________________________ Previously insured by Nationwide Travel Plan? ______ Previous ID Number: ____________ When would you like coverage to begin? (MM/DD/YY) ____/____/____ Destination?: ___________________ Length of Trip?: _______ What is your expected return date? (MM/DD/YY) ____/____/____ Please note: The minimum period of coverage is 5 days, the maximum is 12 months (please see Continuing Coverage Option). Coverage must be purchased in increments of no less than 5 days. Coverage cannot begin until your departure from your Home Country, nor will coverage begin until SRI receives and accepts your application and correct payment. Coverage Specifics Are you traveling: (  ) To the United States or (  ) Outside the United States Policy Maximum: (  ) $50,000  (  ) $100,000  (  ) $500,000 (  ) $1,000,000 Deductible: Option Factor (  )  $0 1.30 (  )  $100 1.10 (  )  $250 1.00 Option Factor (  )  $500 .90 (  )  $1000 .80 (  )  $2500 .70 Continuing Coverage Option: (  ) No  (  ) Yes (must buy at least 3 months) Coverage Option: (  ) Hazardous Sport Coverage (1.15)

Calculating Your Plan Cost (please complete entire section) Date of birth MM/DD/YYYY Monthly Rate Daily Rate Applicant: __________________ ___/___/___     Spouse: ____________________ ___/___/___     Child: ______________________ ___/___/___     Child: ______________________ ___/___/___     Child: ______________________ ___/___/___     Total: $ $ Minimum period of coverage is 5 days Multiply Monthly Rate Total by number of months: X   Monthly Total [A]: $ Multiply Daily Rate Total by number of days: X   Daily Total [B]: $ Total of [A] and [B]: $ Multiply by deductible factor: X   Total: $ Multiply coverage Option Factor: (if applicable) X   Total Payment Enclosed: $ Method of Payment (  ) Check  (  ) Money Order (  ) MasterCard  (  ) Visa  (  ) Discover  (  ) American Express Card Number: ____________________________________ Expiration Date: ____________ Day 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(checks must be issued from a U.S. bank) 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 understand the terms and conditions of this product, as outlined in this brochure. I understand that pre-existing conditions, as defined in Exclusion number 1, are excluded. I understand this program is for persons traveling outside their home country. I hereby subscribe to the American Consumer Insurance Trust and enroll in the group coverage for which I am eligible under the group contract issued by Virginia Surety Company, Inc. (For Special States, it is the Global International Trust by Certain Underwriters at Lloyd's, London). _____________________________________________________ Signature of Insured or Proxy (Required)                   Date (Proxy is someone acting on behalf of the Insured)