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"*" indicates required fields

Hidden
Hidden
Hidden
MM slash DD slash YYYY
Must be under age 71 on Desired Effective Date
MM slash DD slash YYYY
MM slash DD slash YYYY
Hidden
Please confirm foreign travel*
Hidden
DO NOT DELETE THIS FIELD – it is used to calculate number of days, however, since it does not pass to cart correctly, it’s value is copied to the “Number of Days Coverage” field and that field is displayed. This calculated value is also copied to the quantity fields for all premiums. The copied values pass to the cart correctly.
MM slash DD slash YYYY
Hidden
DO NOT DELETE THIS FIELD – it is used to calculate the age of the applicant on Desired Effective date, however, since it does not pass to cart correctly, it’s value is copied to the “Age of Applicant on Desired Effective Date” field and that field is used. The copied value passes to the cart correctly.
Hidden
Hidden
Spouse's Sex*
Must be under age 71 on the Desired Effective Date
MM slash DD slash YYYY
Hidden
Hidden
Hidden
The minimum age is 15 days and the maximum age is 20 years.
Sex – First Child*
Must be under age 21 on Desired Effective Date
MM slash DD slash YYYY
Sex – Second Child*
Must be under age 21 on Desired Effective Date
MM slash DD slash YYYY
Sex – Third Child*
Must be under age 21 on Desired Effective Date
MM slash DD slash YYYY
Price: $0.00
Quantity
Price: $0.00
Quantity
Price: $0.00
Quantity
$0.00
$0.00
$0.00
$0.00
Premium for total number of days covered
Name*
Email*

Declaration of Applicant

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.

Credit Card
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 
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