Liaison
SM Group Travel Plan - Application Form|
Address |
Phone: |
|
|
Fax: |
|
City/ST/Zip: |
E-Mail: |
|
Contact Name: |
Position: |
|
Type of Business: Activities of group: |
|
|
Host Country: | |
|
|
Option A ¨ |
Option B ¨ |
Option C ¨ |
Option D ¨ |
||||
|
Maximum |
$50,000 |
$250,000 |
$50,000 |
$250,000 |
||||
|
Deductible |
$250 |
$250 |
$1,000 |
$1,000 |
||||
|
¨ Traveling Outside the U.S. |
Monthly |
15 Day |
Monthly |
15 Day |
Monthly |
15 Day |
Monthly |
15 Day |
|
Single Premium |
$55 |
$34 |
$75 |
$45 |
$46 |
$28 |
$60 |
$36 |
|
Single + 1 Premium |
$99 |
$60 |
$131 |
$78 |
$81 |
$48 |
$105 |
$64 |
|
Family Premium (max. 5 children) |
$143 |
$85 |
$187 |
$112 |
$115 |
$69 |
$151 |
$91 |
|
¨ Traveling to the U.S. |
Monthly |
15 Day |
Monthly |
15 Day |
Monthly |
15 Day |
Monthly |
15 Day |
|
Single Premium |
$67 |
$40 |
$88 |
$53 |
$54 |
$33 |
$70 |
$42 |
|
Single + 1 Premium |
$117 |
$70 |
$154 |
$92 |
$95 |
$57 |
$124 |
$75 |
|
Family Premium (max. 5 children) |
$168 |
$100 |
$220 |
$132 |
$135 |
$81 |
$178 |
$107 |
|
|
Date of Birth |
Single, Single + 1 or Family |
Effective Date |
Monthly Premium |
Num. of Months |
Total |
15 Day Prem. |
Premium Submitted |
||||
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
|
|
|
|
|
x |
|
= |
|
+ |
|
= |
|
|
Premium Subtotal: |
|
|||||||||||
|
Optional Coverage Factor: 1.15 for Hazardous Sports Ÿ 1.10 for Home Country Coverage Ÿ or 1.25 for both |
x |
|
||||||||||
|
Total Premium Submitted: |
| |||||||||||
If additional space is required, please attach a separate sheet.
Minimum 5 primary insureds in order to be eligible for group coverage.
Can may choose only one premium option (either A,B,C or D).
Minimum and Deposit premium of $500 required with application.
Country(ies) to which the group is traveling: ____________________________________________________________
Has the group purchased insurance through SRI before? Yes
¨ No ¨ If Yes, when? __________________________________________Please note: The minimum period of coverage is 15 days, maximum is 12 months. Coverage must be purchased in increments of no less than 15 days. Coverage can not begin until the insured person departs his/her Home Country, nor will coverage begin until SRI receives your application and correct premium.
When you would like the policy to be effective: _____ / _____ / _____ Will several groups be sent overseas?: Yes No
Payment for the entire period of coverage is due at the time this application is submitted to SRI. Naturally, monthly billing arrangements are available for significant-sized groups who will be spending more than 1 month overseas. Please contact SRI to establish a procedure for billing.
Corporate Check
¨ Money Order ¨ Visa ¨ MasterCard ¨Card # __________________________________________________ Expiration Date: _________________________
Name as it appears on card: _________________________________ Daytime Phone: _________________________
Signature (Required): ___________________________________________________
Billing Address: ___________________________________________________________________________________
I declare that I understand the terms and conditions of this product (of which I am purchasing on behalf of the organization), as outlined in the LiaisonSM Group Travel Plan brochure and its insert, including the preexisting condition exclusion.
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 credit card company.
I hereby subscribe the organization to the Global International Trust and enroll the participants in the group coverage for which I am eligible under the group contract issued by The MEGA Life and Health Insurance Company.
________________________________________________________________
Signature of Assured (Required) ........................ Date
|
Agent Name: Global Cover (Genesis International Group, Inc.) |
SRI Agent #: 1806 |
|
Address: 107 81st Avenue |
Phone: 1-866-452-6837 |
|
Fax: 1-212-504-8085 |
|
|
City/St/Zip: Kew Gardens, NY 11415 |
E-Mail: marketing@globalcover.com |