International Major Medical Insurance

Applicant

# of Applicants

Are you a USA Citizen? Are any applicants USA citizen?

Yes No

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

Gender

First Name

Last Name

Date of Birth mm/dd/yyyy

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 cannot be purchased in the following states: GU, MD, NM, NY, SD

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