By clicking the “Continue” button below, I hereby apply to purchase the insurance and I consent to the collection, use and disclosure of my personal information in connection with HealthCare International for the purposes outlined in the Privacy Policy. If I do not consent to the collection, use and disclosure of my personal information in connection with the Privacy Policy, I understand that I will not be able to purchase the HealthCare International policy. I declare to the best of my knowledge and belief that the information given in this Application is true and complete. I acknowledge (on behalf of the person(s) to be insured) that benefits will not apply to treatment arising from pre-existing medical conditions. It is agreed that this declaration and the information given herein shall form the basis of the contract between the Insured Person and the Company. Further, I hereby subscribe to the International Sojourners Insurance Trust and acknowledge enrolling in this group coverage for which I am eligible under the contract issued by the Company.

By submitting this Application you agree to the terms of the Applicant Declaration.

Your insurance documents will be sent to the email address supplied with this enrollment form.