| Distributed by Insurance
Services of America
Why
Buy Travel Insurance?
Am I
Eligible for the Atlas Series?
When
Does Coverage Become Effective and When Does It End?
Does The
Atlas Series Provide Any Home Country Coverage?
How is
"Home Country" Defined?
Which
Plan Should I Purchase?
What
Is Covered?
How
Much is the Premium?
What
Are The Policy Limits?
What
Is Excluded?
What If
I Plan to Participate in a Sport or Athletic Activity that is Excluded?
What
If I Have an Acute Onset of a Pre-Existing Condition?
What
Are the Pre-Notification Requirements?
Who Is
The Plan Administrator?
Who
is the Insurer
How
Do I Apply?
APPLY ONLINE
|
Why Buy Travel Insurance? |
| |
The answer is easy. Whether you travel for business or pleasure,
international travel involves risk. You may arrive at your destination
to find that your luggage with personal items has disappeared. A
personal emergency may necessitate your early return to your Home
Country. A medical emergency may require hospitalization or even air
evacuation. In most cases, your existing insurance will not provide
adequate protection for these and other risks. Without appropriate
travel insurance, you may be exposed to significant financial liability.
MultiNational Underwriters, Inc. has designed The Atlas Series to take
the risks out of international travel, so you can have an enjoyable and
productive trip.
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|
Am I Eligible For The Atlas Series? |
| |
If you are traveling outside of your Home Country and are at least 14
days old, you are eligible for coverage. If you are under age 70, you
may select your Overall Maximum Limit, ranging from $50,000 to
$1,000,000. If you are age 70 to 79, the Overall Maximum Limit available
is $50,000. If you are age 80 or older, the Overall Maximum Limit
available is $10,000. The minimum coverage period is 15 days and the
maximum coverage period is 12 months. You may purchase coverage in a
combination of monthly and 15-day increments, depending on your needs.
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|
When Does Coverage Become Effective and When Does It End? |
| |
Your coverage becomes effective on the latest of: the date we receive
your Application and correct premium, the moment you depart from your
Home Country or the date you request on your Application. Your coverage
will end on the earliest of: the end of the period for which you have
paid a premium, the date requested on your Application, or the moment of
your arrival upon return to your Home Country (unless you have started a
Benefit Period or are eligible for Home Country Coverage under the Atlas
Extra plan).
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|
Does The Atlas Series Provide Any Home Country Coverage? |
| |
Yes. Under certain circumstances, the Atlas Series will provide
limited Home Country Coverage. If you purchase the Atlas Series for at
least 3 months, and you purchase the Incidental Home Country Rider, you
are covered for medical expenses only during one Incidental trip to your
Home Country of up to 10 days. If you started a Benefit Period while
your insurance under the Atlas Series was in effect, you are covered for
medical expenses only for the duration of the Benefit Period, regardless
of whether you are at home or abroad. Your Benefit Period begins on the
first date you receive a diagnosis or treatment of a covered illness or
injury while outside your Home Country and lasts for 180 days. If you
have purchased Atlas Extra and have maintained coverage for at least 6
months, the plan provides Home Country Coverage for up to 30 days if you
purchase the 30 day period at the time of application.
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|
How is “Home Country” Defined? |
| |
If you are a US citizen, your Home Country is the United States,
regardless of the location of your Principal Residence. If you are not a
US citizen, your Home Country is the country where you principally
reside and receive regular mail.
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|
Which Plan Should I Purchase? |
| |
If you are a US citizen traveling abroad for 6 months or less, you
should purchase Atlas International. If you are a non-US citizen
traveling outside your Home Country for 6 months or less, you should
purchase Atlas America. Regardless of your citizenship, if you are
planning on traveling for 6 months or more, you should purchase Atlas
Extra. The minimum period for Atlas Extra is 6 months.
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|
What Is Covered? |
| |
All benefits, except Lost Checked Luggage, Accidental Death &
Dismemberment and Common Carrier Accidental Death, are subject to the
Deductible and Coinsurance. Policy Limits apply to all benefits:
Medical:
- Inpatient and Outpatient charges made by a Hospital.
- Charges made by a Physician, surgeon, radiologist,
anesthesiologist, and any other medical specialist to whom the
Physician has referred the case.
- Charges made for dressings, sutures, casts or other supplies
prescribed by the attending Physician or specialist.
- Charges for diagnostic testing using radiology, ultrasonographic
or laboratory services.
- Charges for oxygen and other gases and anesthetics and their
administration.
- Charges for prescription drugs, for treatment of a covered Injury
or Illness, but not for the replacement of lost, stolen, damaged,
expired or otherwise compromised drugs.
- Charges made by a licensed Extended Care Facility upon direct
transfer from an acute care Hospital.
- Emergency local ambulance transport incurred in connection with
Injury or Illness resulting in hospitalization.
Emergency Dental:
- Emergency Dental treatment and Dental surgery necessary to restore
or replace sound natural teeth lost or damaged in an Accident which
is covered under this insurance.
- Emergency Dental treatment necessary to resolve acute, spontaneous
and unexpected onset of pain.
Emergency Evacuation:
If recommended by your attending Physician, who certifies that
Evacuation is necessary to safeguard your life and that Medically
Necessary treatment is not available locally, and if approved in advance
and coordinated by MultiNational Underwriters, Inc., the Atlas Series
will provide the following benefits: Emergency air and/or ground
transportation to the nearest Hospital that is qualified to provide the
Medically Necessary treatment.
Emergency Reunion:
In the event of a covered Emergency Evacuation, the Atlas Series will
provide the following benefits: The cost of an economy round trip air
and/or ground transportation ticket for one of your relatives (parent,
spouse, sibling or child age 18 or older) for transportation to the area
where you are hospitalized following Emergency Evacuation and reasonable
expenses for lodging and meals for your relative, for a period not to
exceed 10 days.
Trip Interruption:
- If, after you have departed, you learn of the death of a parent,
spouse, sibling or child, or you learn of the substantial
destruction of your Principal Residence by fire or weather, the
Atlas Series will provide the following benefit: The cost of an
economy one way air and/or ground transportation ticket for you to
the area of your Principal Residence; or
- Following a covered Emergency Evacuation, the attending Physician
states that it is Medically Necessary for your return to your Home
Country or to the area from which you were initially evacuated for
continued treatment, recuperation and recovery, the Atlas Series
will provide the following benefit: The cost of a one way economy
air and/or ground transportation ticket for your transportation from
the area where you were hospitalized following the Emergency
Evacuation, to the area where you were initially evacuated from, or
to the terminal serving the area of your Principal Residence.
Repatriation of Remains:
In the event of a covered Injury or Illness resulting in your death,
the Atlas Series will provide the following benefit: Air and/or ground
transportation of bodily remains or ashes to the area of your Principal
Residence, and reasonable costs of preparation of your remains necessary
for transportation.
Lost Checked Luggage:
In the event your checked luggage is permanently lost by the carrier,
the Atlas Plan will provide the following benefit: Up to $250 for
replacement of clothes and personal hygiene items, not to exceed $50 for
any one item. You must file a formal claim with the transportation
provider and provide the Plan Administrator with copies of all claim
forms and proof that the transportation provider has paid you its normal
reimbursement for the lost checked luggage.
Accidental Death and Dismemberment:
In the event of your Accidental Death (except while traveling on a
common carrier) or Dismemberment resulting from a covered Injury, the
Atlas Series will provide the following benefit:
- Accidental Death – Principal Sum of $25,000 to the Beneficiary
designated on your Application. The Principal Sum shall reduce by
50% (to $12,500) if you are age 70 to 74 at time of Death, and an
additional 50% (to $6,250) if you are age 75 or older at time of
Death.
- Accidental Dismemberment
a. Loss of 2 eyes or 2 or more limbs –- Principal Sum of $25,000
to you.
b. Loss of 1 eye or limb – One-half of the Principal Sum ($12,500)
to you.
c. The Principal Sum(s) shall reduce by 50% if you are age 70 to 74
at time of Dismemberment, and an additional 50% if you are age 75 or
older at time of Dismemberment.
- The Accidental Death Dismemberment benefit is deleted during
participation in a hazardous sport
Common Carrier Accidental Death:
In the event of your accidental death while traveling on board a
commercial common carrier, the Atlas Series will provide the following
benefit: Principal Sum of $50,000 to the Beneficiary designated on your
Application
Return of Minor Child(ren):
If you are the only person age 18 or older, traveling with one or
more Minor Children under the age of 18, who are also covered by the
Atlas Series, and you are Hospitalized for treatment of a covered
Illness or Injury, resulting in the child(ren) being left unattended for
a period of time expected to exceed 36 hours, the Atlas Series will
provide the following benefit: The cost of a one way economy air and/or
ground transportation ticket for each covered Minor Child to the
terminal serving the area of Principal Residence of each covered Minor
Child.
Atlas Travel Assistance Services:
The following Travel Assistance Services are available to you 24
hours a day, 7 days a week while your Atlas plan is in effect.
Pre-Trip Health and Safety Advisories (available after your
purchase of the Atlas Series, and before your departure) – call us for
current passport, visa, inoculation and vaccine requirements, as well as
up-to-date travel safety advisories.
Livetravel Services – we will make emergency travel and
itinerary changes for you including rebooking flights, hotel
reservations and ground transportation arrangements.
BagTrak – we are the industry leaders in tracking lost baggage.
We will help you locate your lost baggage, and deliver it to you
anywhere in the world.
Emergency Message Relay – we will relay messages to your
family, friends and co-workers, helping you to maintain contact during
an emergency.
Emergency Cash Transfers – we will assist you in arranging and
obtaining cash transfers anywhere in the world.
Other important Atlas Travel Assistance Services include:
- Medical referrals
- Up-to-the-minute travel medical advisories
- Assistance with prescription drug replacement
- Dispatch of a doctor or specialist
- Emergency travel arrangements for family members
- Lost passport or travel documents assistance
- Embassy and consulate referrals
- Legal and accounting referrals
- Bail bond assistance
- Translation and interpretation assistance
Atlas Travel Assistance Services are not insurance benefits and
provision of any Atlas Travel Assistance Services is not a guarantee of
any other benefit under the Atlas Series.
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|
How Much is the Premium?
|
| |
Atlas International -- US Citizens
Traveling Abroad
| |
Option 1
$50,000
|
Option 2
$100,000
|
Option 3
$250,000
|
Option 4
$1,000,000
|
|
Age
|
One Month
|
15 Days
|
One Month
|
15 Days
|
One Month
|
15 Days
|
One Month
|
15 Days
|
|
18-29
|
$35
|
$18
|
$41
|
$21
|
$45
|
$23
|
$51
|
$26
|
|
30-39
|
$41
|
$21
|
$47
|
$24
|
$59
|
$30
|
$69
|
$35
|
|
40-49
|
$65
|
$33
|
$75
|
$38
|
$80
|
$40
|
$90
|
$45
|
|
50-59
|
$106
|
$53
|
$120
|
$60
|
$128
|
$64
|
$145
|
$73
|
|
60-64
|
$131
|
$66
|
$146
|
$73
|
$186
|
$93
|
$205
|
$103
|
|
65-69
|
$164
|
$82
|
$180
|
$90
|
$188
|
$94
|
$220
|
$110
|
|
70-79
|
$208
|
$104
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
$420
|
$210
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
Dependent child
|
$18
|
$9
|
$20
|
$10
|
$29
|
$15
|
$32
|
$16
|
|
Child alone
|
$35
|
$18
|
$40
|
$20
|
$44
|
$22
|
$49
|
$25
|
*$10,000 Limit
Atlas America -- Non-US Citizens
Traveling Outside Home Country
| |
Option 5
$50,000
|
Option 6
$250,000
|
Option 7
$500,000
|
|
Age
|
One Month
|
15 Days
|
One Month
|
15 Days
|
One Month
|
15 Days
|
|
18-29
|
$47
|
$24
|
$64
|
$32
|
$70
|
$35
|
|
30-39
|
$61
|
$31
|
$81
|
$41
|
$94
|
$47
|
|
40-49
|
$95
|
$48
|
$128
|
$64
|
$140
|
$70
|
|
50-59
|
$132
|
$66
|
$174
|
$87
|
$198
|
$99
|
|
60-64
|
$158
|
$79
|
$237
|
$119
|
$250
|
$125
|
|
65-69
|
$200
|
$100
|
$277
|
$139
|
$278
|
$139
|
|
70-79
|
$255
|
$128
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
$425
|
$213
|
N/A
|
N/A
|
N/A
|
N/A
|
|
Dependent child
|
$28
|
$14
|
$34
|
$17
|
$40
|
$20
|
|
Child alone
|
$42
|
$21
|
$54
|
$27
|
$65
|
$33
|
*$10,000 Limit
Atlas Extra
|
|
US Citizens
|
All Others
|
| |
Option 8
$500,000
|
Option 9
$1,000,000
|
Option 10
$500,000
|
Option 11
$1,000,000
|
|
Age
|
One Month
|
One Month
|
One Month
|
One Month
|
|
18-25
|
$38
|
$44
|
$62
|
$73
|
|
26-29
|
$43
|
$48
|
$67
|
$76
|
|
30-39
|
$56
|
$60
|
$83
|
$95
|
|
40-49
|
$72
|
$81
|
$123
|
$138
|
|
50-59
|
$134
|
$145
|
$186
|
$205
|
|
60-64
|
$176
|
$190
|
$229
|
$255
|
|
65-69
|
$186
|
$200
|
$269
|
$300
|
|
70-79*
|
$375
|
N/A
|
$450
|
N/A
|
|
80+**
|
$375
|
N/A
|
$450
|
N/A
|
|
Dependent child
|
$26
|
$28
|
$32
|
$43
|
|
Child alone
|
$38
|
$43
|
$60
|
$70
|
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|
Schedule of Benefits and Limits
|
| |
| Deductibles: |
$100, $250, $500,
$1,000 or $2,500 per Certificate Period. |
| Coinsurance - Claims incurred in
US or Canada: |
For the Certificate
Period, Underwriters will pay 80% of the next $5,000 of Eligible
Expenses after the Deductible, then 100% to the Overall Maximum
Limit. |
| Coinsurance - Claims
incurred outside US or Canada: |
For the Certificate
Period, Underwriters will pay 100% of Eligible Expenses after
the Deductible up to the Overall Maximum Limit. |
| Hospital Room and Board: |
Average Semi-private
room rate, including nursing services. |
| Intensive Care Unit: |
Usual, Reasonable and
Customary charges |
| Outpatient Treatment: |
Usual, Reasonable and
Customary charges |
| All Other Eligible Expenses: |
Usual, Reasonable and
Customary charges. |
| Acute Onset of
Pre-existing Condition: |
Atlas Extra - $2,500
limit; Atlas International - $1,000 Limit; Atlas America - No
Coverage |
| Emergency Dental - Acute onset of
pain: |
$100 limit per
Certificate Period |
| Local Ambulance: |
Usual, Reasonable and
Customary charges. |
| Emergency Evacuation: |
Overall Maximum Limit |
| Repatriation of
Remains: |
Overall Maximum Limit |
| Emergency Reunion: |
$10,000 limit per
Certificate Period |
| Trip Interruption: |
$5,000 limit per
Certificate Period |
| Lost Checked Luggage: |
$250 limit per
Certificate Period (not subject to Deductible or Coinsurance) |
| Accidental Death and
Dismemberment: |
Death - $25,000 Loss
of 2 Limbs - $25,000 Loss of 1 Limb - $12,500 .Benefits reduce
50% at age 70 and an additional 50% at age 75. |
| Common Carrier Accidental Death: |
$50,000 |
| Hospital
Pre-Certification Penalty: |
50% of Eligible
Medical Expenses. |
| Optional Hazardous Sports Rider: |
Overall Maximum Limit |
| Overall
Maximum Limit per Certificate Period (includes all benefits
except Accidental Death and Dismemberment and Common Carrier
Accidental Death): |
Age 14
days to 69 - $50,000, $100,000, $250,000, $500,000 or
$1,000,000.
Age 70 to 79 - $50,000
Age 80 or older - $10,000. |
| Return of Minor
Children |
$5,000 limit |
| Physical Therapy |
$50 per visit |
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|
What Is Excluded? |
| |
The following charges, treatments, surgeries, medications, conditions
and circumstances:
- Pre-existing Conditions – Charges resulting directly or
indirectly from any Pre-existing Condition are excluded from this
insurance, except, if you purchase Atlas Extra or Atlas
International, you are covered for charges resulting from an Acute
Onset of a Pre-existing Condition, up to the limit set forth in the
Schedule of Benefits and Limits. A Pre-existing Condition is any
Illness, Injury or medical condition or chronic or recurring Illness
or Injury or medical condition, including any associated
complications or consequences, which existed at or during the 5
years immediately preceding your effective date. An Acute Onset is a
sudden and unexpected outbreak or recurrence of a Pre-existing
Condition, which occurs spontaneously and without advance warning
either in the form of Physician recommendations or symptoms.
Treatment must be obtained within 24 hours of the sudden and
unexpected outbreak or recurrence.
- Treatment for or related to any congenital condition.
- Pregnancy, child birth, birth control, artificial insemination,
infertility, impotency or sexual dysfunction, sterilization or
reversal thereof.
- Mental Health Disorders or Substance Abuse.
- Not incurred during the Certificate Period or the applicable
Benefit Period, and charges which are not presented to Underwriters
for payment within 60 days from the end of the Certificate Period or
the applicable Benefit Period.
- Charges for use of Emergency Room for treatment of Illness unless
the patient is directly admitted to the Hospital as Inpatient for
further treatment of that Illness.
- Not Medically Necessary and administered or ordered by a
Physician.
- Provided at no cost, or by a family member, or by a person who
ordinarily resides with you, or which are attributable to or
recoverable from any other party including government sponsored
plans.
- Charges which exceed Usual, Reasonable and Customary.
- Investigational, Experimental or for Research purposes.
- While confined primarily to receive Custodial Care, Educational or
Rehabilitative care.
- Venereal Disease, AIDS or ARC.
- Dental treatment, including treatment of the temporomandibular
joint, except for Emergency Dental treatment necessary to replace
sound natural teeth lost or damaged in an Accident covered hereunder
or for the relief of Acute, spontaneous and unexpected onset of
pain.
- Eyeglasses, contact lenses, hearing aids, hearing implants, eye
refraction, visual therapy, orthoptics or visual eye training or eye
surgery (including cataract surgery and radial keratotomy) or for
any examination or fitting related to these devices or procedures.
- Injury sustained while taking part in the following activities:
Amateur or professional sports or athletics, except this does not
include Amateur sports or athletics which are non-contact and
undertaken solely for leisure, recreational, entertainment or
fitness purposes unless such sports or athletics are otherwise
excluded by this provision. The following are excluded:
Mountaineering where ropes or guides are normally used or at
elevations of 4,500 meters or higher. Aviation, except when
traveling solely as a passenger in a commercial aircraft. Hang
gliding, sky diving, parachuting or bungee jumping; Snow skiing or
snowboarding, except for recreational downhill and/or cross-country
snow skiing or snowboarding (no cover provided whilst skiing away
from prepared and marked in-bound territories and/or against the
advice of the local ski school or local authoritative body); Racing
by any animal or motorized vehicle; and spelunking; and subaqua
pursuits involving underwater breathing apparatus unless NAUI/PADI
certified, accompanied by a certified instructor, and at depths of
less than 10 meters; jet skiing; and any other sport or athletic
activity which is undertaken for thrill seeking and exposes you to
abnormal or extreme risk of injury.
- Injury sustained while under the influence of or due wholly or
partly to the effects of intoxicating liquor or drugs other than
drugs taken in accordance with treatment prescribed and directed by
a Physician but not for the treatment of Substance Abuse.
- Willfully self-inflicted Injury or Illness and immunizations and
Routine Physical Exams.
- The Deductible, and Coinsurance and charges which are not included
as Eligible Expenses as described in the Master Policy, and charges
which exceed the policy limits.
- Treatment required as a result of complications or consequences of
a treatment or condition not covered hereunder.
- Charges for travel or accommodations, except as provided for in
the Local Ambulance, Emergency Medical Evacuation, Repatriation of
Remains, Emergency Reunion and Trip Interruption sections of this
insurance.
- Treatment incurred as a result of exposure to non-medical nuclear
radiation and/or radioactive material(s).
- Organ or tissue transplants or related services.
- Acts of terrorism, war, insurrection, riot or any variation
thereof.
- Treatment by a Chiropractor.
- Diseases of the skin.
This is a summary of exclusions. For more details, or for a complete
copy of the Master Policy, contact MultiNational Underwriters, Inc.
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|
What If I Plan to Participate in a Sport or Athletic Activity that
is Excluded? |
| |
The Optional Hazardous Sports Rider is available for the adventurous
traveler. This Rider adds coverage for the Amateur sports, listed in
exclusion #15. The maximum policy limit under this rider is the Overall
Maximum Limit you select. The Accidental Death and Dismemberment benefit
is deleted during the course of the activity.
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|
What If I Have an Acute Onset of a Pre-Existing Condition? |
| |
If you purchase Atlas Extra, you are covered up to $2,500; or Atlas
International, you are covered up to $1,000 for a sudden and unexpected
outbreak or recurrence of a Pre-existing Condition, which occurs
spontaneously and without advance warning either in the form of a
Physician recommendation or symptoms, and which occurs while this
coverage is in effect. Treatment must be obtained within 24 hours of the
sudden and unexpected outbreak or recurrence.
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|
What Are the Pre-Notification Requirements? |
| |
All Hospitalizations, Surgeries, Emergency Evacuations, Emergency
Reunions, Trip Interruptions, Repatriation of Remains, Computerized
Tomography (CAT Scan) and Magnetic Resonance Imaging (MRI) must be
Pre-notified. Simply call, or have your Physician call, MultiNational
Underwriters, Inc. with all information relative to your claim. Be sure
to have your ID number available. If you do not Pre-notify, medical
expenses will be reduced by 50%, and all other expenses will be
forfeited.
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|
Who Is The Plan Administrator? |
| |
MultiNational Underwriters, Inc., headquartered in Indianapolis,
Indiana, is a full service organization offering a comprehensive
portfolio of insurance products designed specifically to address the
insurance needs of international travelers. As a TRAVEL GUARD®
International company, we benefit from the experience of a corporate
group that protected over 6 million travelers last year. Our
international claims specialists, medical professionals and customer
service representatives are available 24 hours a day, 7 days a week to
answer your questions and respond to your needs. Whether you have lost
your luggage or are in need of Emergency Evacuation, you will find our
service team to be prompt, compassionate, and of the highest
professional quality.
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|
How Do I Apply? |
| |
It's easy. Just print and complete the following application or go to
online
quotes and applications
Mail the completed form, along with your payment, to:
Insurance Services of
America
1757. E. Baseline Road, Suite 126
Gilbert, AZ 85233
If paying by credit card, you may fax your application to
480.821.9297
or E-mail it to health@missionaryhealth.net
APPLICATION:
Please Print your Name (as you would like it to
appear on your ID card):
| (Last) |
(First) |
(Middle) |
| Passport #: |
| Send Certificate of Insurance to:
(if different than above) |
| Name: |
| Address: |
| Telephone: |
Fax: |
| Requested Effective Date: |
Date of Departure: |
| Date of Return to Home Country: |
Country of Citizenship: |
| Countries to be visited: |
Name of Beneficiary:
(Note: You will be the Beneficiary for spouse and dependent
children included on this Application.) |
HOW DO I CALCULATE MY PREMIUM?
Follow these instructions:
| 1. Select One Plan and One Option: |
|
| ATLAS INTERNATIONAL |
Option #1 |
Option #2 |
Option #3 |
Option #4 |
| ATLAS AMERICA |
Option #5 |
Option #6 |
Option #7 |
| ATLAS EXTRA |
Option #8 |
Option #9 |
Option #10 |
Option #11 |
2. List the names of individuals to be covered, and
the appropriate premium for the Plan and Option selected:
| Name |
Date of Birth |
Monthly Premium |
15 day Premium |
| Applicant: |
|
|
|
| Spouse: |
|
|
|
| Child: |
|
|
|
| Child: |
|
|
|
| Child: |
|
|
|
| Subtotal: |
A. $ |
B. $ |
3. Complete the following:
A.$ __________
(from above) |
X |
__________
(number of months) |
= |
C.$ __________ |
| C.$ __________ |
+ |
B.$ __________
(from above) |
= |
D.$ __________ |
| D.$ __________ |
X |
__________
(Deductible Factor) |
= |
F.$ __________ |
F.$ __________
(Optional Hazardous
Sports Rider) |
X |
1.20 |
= |
G.$ __________ |
G.$ __________
(Incidental Home
Country Rider*) |
X |
1.10 |
= |
H.$ __________ |
| H.$ __________ |
+ |
$ 15.00
(optional overnight charge to U.S. Address) |
= |
I.$ __________ |
| I.$ __________ |
+ |
$ 25.00
(optional overnight charge to Non-U.S. Address) |
= |
J.$ __________ |
| J.$ __________ |
+ |
$ 5.00
(Non-refundable Policy Fee) |
= |
K.$ __________
TOTAL PAYMENT |
* Optional and Available only when purchasing a minimum of 3
months.
| All Products - Deductible Factors
| $100 - 1.10 |
$250 - 1.00 |
$500 - .95 |
$1000 - .85 |
$2500 - .75 |
|
| 4. If you are purchasing the Hazardous Sports
Rider, please describe the activities for which you are seeking
coverage:
|
5. Complete the following:
| Payment Mode: |
Check/Money Order |
MasterCard |
| Visa |
American Express |
| Credit Card #: |
Expiration Date: |
| Name as it appears on card: |
| Signature: |
Daytime Phone #: |
| Billing Address:
|
| Check or Money Orders should be
made payable, in US dollars, to MultiNational Underwriters, Inc.
If paying by credit card, I authorize MultiNational
Underwriters, Inc. to debit my VISA, MasterCard or American
Express account for the amount specified in H. above. Coverage
purchased by credit card is subject to validation and acceptance
by the credit card company. |
6. Read and sign below.
| I hereby apply for membership in the
Atlas/International Citizen Group Insurance Trust, for the
insurance provided to members by Lloyd's. I understand that this
is not a general health insurance policy and that it is intended
for use in the event of a sudden and unexpected event while I am
traveling outside of my Home Country. I understand that
Pre-existing Conditions are not covered. I understand this
insurance contains a Pre-certification Penalty, and other
restrictions and exclusions. I understand this insurance is not
renewable and successive periods of insurance will require
re-satisfaction of the Deductible and Coinsurance. I understand
that the information contained herein is a summary of the Master
Policy, and that I may obtain a complete copy of the Master
Policy upon request. I understand that Lloyd's operates as an
approved but non-admitted insurer in all states of the United
States except Illinois and Kentucky where they are admitted. As
such, claims under this insurance may not be made against any
state guaranty fund. If signed by an agent of the Applicant, the
undersigned warrants his/her capacity to so act. By acceptance
of coverage, the Applicant ratifies the authority of the
signatory to bind him/her. The undersigned authorizes any
doctor, medical practitioner, hospital, clinic, health facility,
pharmacy, government agency, insurance agency, insurance
company, group policyholder or insurance or benefit
administrator or any other entity having information as to the
care, advice, treatment, diagnosis or physical or mental
condition of any person listed on this Application to release
said information to MultiNational Underwriters, Inc. |
Signature of Applicant (or
Guardian):_______________________ Date:__________
Signature of Spouse:_______________________
Date:__________
|
7. For Agent Use Only:
| Producer Number: 9870 |
Producer Name: |
| Company Name: Insurance Services of America |
Mailing Address: 1757. E. Baseline Road, Suite 126 |
| City: Gilbert |
State: AZ |
Postal Code 85233 |
| Country: USA |
Telephone: 800-647-4589 |
Fax: 480-821-9297 |
| E-mail Address: health@missionaryhealth.net |
Signature: |
Insurance Services of America
1757. E. Baseline Road, Suite 126, Gilbert, AZ 85233
800-647-43589 / 480-821-9297 (fax)
480-821-9052 (worldwide)
Email: health@missionaryhealth.net
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