1. Insured Information

Email Address:
(Your Confirmation of Insurance will be sent via email.)
Home Address - Street:
City:
State:
Province: Postal Code:
Country:
Day Phone:
Evening Phone:

(You must include at least one phone number.)
Departure Date:
Destination Country:
Beneficiary:
(FirstName Surname)
(You will be the beneficiary for your insured spouse and children.)
Beneficiary Relationship:

2. Applicants' Information

 
Insured (Primary):
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Spouse:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#1:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#2:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#3:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#4:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#5:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#6:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#7:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#8:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 
 
Dependent#9:
  First Name Surname Middle Initial
 
  Date of Birth Citizenship Gender
 

3. Requested Coverage Period (Applies to all applicants)

Effective Date(mm/dd/yyyy): Calendar
Expiration Date(mm/dd/yyyy): Calendar (Cannot be more than 12 months after Effective Date)

4. Plan Selection (Applies to all applicants)

Choose Plan: Plan A Plan B Plan C
Choose Deductible: $0 $250 $500 $1,000
Additional AD&D: No $50K
Intercollegiate Sports Coverage: No Yes
Hazardous Activities: No Yes

5. Enrollment Agreement

I hereby apply for membership in the Atlas/International Citizen Group Insurance Trust, Hamilton, Bermuda and for the insurance provided to members by Lloyd’s. I understand that the personal information I am submitting in this section will result in automated decisions. For further information on how we process your personal information please see our Privacy Policy https://www.worldtrips.com/about-worldtrips/privacy-policy/. When we make an automated decision about you, you have the right to contest the decision, to express your point of view, and to require a human review of the decision. Please contact your producer for additional information. I understand that the insurance applied for is not a general health insurance policy, but is intended for use in the event of a sudden and unexpected event while traveling outside my Home Country. I understand that my insurance terminates upon my return to my Home Country unless I qualify for a Benefit Period or Home Country Coverage. I understand this insurance contains a Pre-existing Condition exclusion and other restrictions and exclusions. I understand that, prior to my current coverage expiration date, I can visit the WorldTrips Client Zone for transaction instructions regarding policy Extensions and/or Renewal eligibility. I understand that if my insurance is not Extended or Renewed prior to or on the current coverage expiration date I must purchase a new policy in order to have coverage. 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 to WorldTrips. It is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India. I understand that Lloyd’s, as underwriter of the plan, is solely liable for the coverage and benefits provided under the insurance. I understand that Lloyd’s operates as an approved, 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. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant, and as a representative, authorize WorldTrips to provide any applicable claims Explanation of Benefits (EOB) to assist communication in the claims process. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement, or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable. Except for certain types of disputes described in the "Arbitration and Class Action Waiver" in your policy wording, and if you do not opt-out as set forth in that same section, you agree that disputes between you and WorldTrips and/or the Underwriters will be resolved by binding, individual arbitration, and you waive your right to bring or resolve any dispute as, or participate in, a class, consolidated, representative, collective, or private attorney general action or arbitration. If requesting cancellation, I understand that I must notify WorldTrips or my insurance agent/broker, in writing, prior to the effective date for a full refund and that express delivery charges are not refundable.

I agree to enroll under the conditions of this Enrollment Agreement.

6. Location Verification

By checking this box, I confirm that I am not currently physically located in the State of Maryland, New York, or Washington, or in the Country of Canada or Australia.