1. Insured Information
Email Address:
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(Your Confirmation of Insurance will be sent via email.) |
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| Home Address - Street: |
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| City: |
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| State: |
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| Province: |
Postal Code:
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| Country: |
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Applicant cannot be located in the home country at time of purchase |
| Day Phone: |
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Evening Phone:
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(You must include at least one phone number.) |
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| Departure Date: |
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| Destination Country: |
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| Beneficiary: |
(FirstName Surname)
(You will be the beneficiary for your insured spouse and children.)
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| Beneficiary Relationship: |
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2. Applicants' Information
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| Insured (Primary): |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Spouse: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#1: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#2: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#3: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#4: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#5: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#6: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#7: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#8: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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| Dependent#9: |
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First Name |
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Surname |
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Middle Initial |
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Date of Birth |
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Citizenship |
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Gender |
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3. Requested Coverage Period (Applies to all applicants)
4. Plan Selection (Applies to all applicants)
5. Enrollment Agreement
The Applicant, or the Sponsoring Organization (Sponsor) if applicable, on behalf of and as authorized agent and proxy for each of the group participants listed on the Application, hereby applies for coverage under membership in the TMHCC (CI) – Travel Trust, Cayman Islands and for the insurance provided to members by TMHCC (CI) Insurance SPC Ltd. The Applicant or Sponsor and each group participant understands that the personal information submitted in this section will result in automated decisions. For further information on how we process your personal information please see our 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. The Applicant or Sponsor and each group participant understands 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 their Home Country(ies). The Applicant or Sponsor and each group participant understands that insurance terminates upon return to the Home Country unless qualifying for a Benefit Period. The Applicant or Sponsor and each group participant understands this insurance may contain a Pre-existing Condition exclusion and other restrictions and exclusions. The Applicant or Sponsor and each group participant understands that renewal of this insurance is subject to continued eligibility and will not be effective unless confirmed in writing by WorldTrips. Renewal eligibility is subject to plan type. If individual coverage is not renewed or extended, successive periods of insurance will require re-satisfaction of the Deductible, Coinsurance, Pre-existing Condition provision, and all other conditions of the insurance following acceptance of a new Enrollment. The Applicant or Sponsor and each group participant understands that the information contained herein is a summary of the Master Policy and that that they may obtain a complete copy of the Master Policy upon request to WorldTrips. The Applicant or Sponsor and each group participant understands and agrees that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant or Sponsor, and as a representative, authorizes 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 or Sponsor, 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, or if applicable, each group participant, ratifies the authority of the signer to so act and bind the Applicant or group participant.
Notice. Except for certain types of disputes described in the "Arbitration and Class Action Waiver" in your policy wording and also available here, and if you do not opt-out as set forth in that same section, you agree that disputes between you and the WorldTrips and/or the Insurers 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.
Payment and Cancellation Notice. I authorize USI Insurance Services to debit my credit card for the amount specified above. I understand that coverage purchased by credit card is subject to validation and acceptance by the credit card company. If requesting cancellation, I understand that I must notify USI, 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 countries of Australia, Austria, Belgium, Bulgaria, Canada, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden.