International Major Medical Insurance

Applicant

# of Applicants

Country of Citizenship

First Name

Last Name

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Gender

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Date of Birth mm/dd/yyyy

Gender

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Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

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Date of Birth mm/dd/yyyy

Gender

First Name

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Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

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Date of Birth mm/dd/yyyy

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Gender

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Gender

I hereby confirm that the individuals listed above are not an Employer Group.

Effective Date mm/dd/yyyy

Expiry Date mm/dd/yyyy

THIS IS NOT QUALIFYING HEALTH COVERAGE ("MINIMUM ESSENTIAL COVERAGE") THAT SATISFIES THE HEALTH COVERAGE REQUIREMENT OF THE AFFORDABLE CARE ACT. IF YOU DON'T HAVE MINIMUM ESSENTIAL COVERAGE, YOU MAY OWE AN ADDITIONAL PAYMENT WITH YOUR TAXES.

This plan does not cover pre-existing conditions.

This plan does not cover preventative care.

This plan does not satisfy the visa requirement for travel longer than 6 months per the 10/4/19 presidential proclamation.

Coverage is NOT available online in the following countries: Afghanistan, Belarus, Cuba, Iran, Israel (Excluding Gaza Strip And West Bank), Israel - Gaza Strip Only, Israel - West Bank Only, North Korea, Russia, Sudan, and Ukraine

Coverage cannot be purchased in the following states: AK, CO, CT, DE, GU, IA, IL, KY, MD, ME, MO, MS, MT, NC, NE, NJ, NM, NY, OR, RI, SC, SD, TN

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CA License #: 0591207