1. Visitor Information

Insured First Name:
Surname: Middle Initial:
Email Address:
(Your Confirmation of Insurance will be sent via email.)
Home Country Address  
Street:
City:
State/Province: Postal Code:
Country:
Departure Date from Home Country:
Beneficiary: (FirstName Surname)
(You will be the beneficiary for your insured spouse and children.)
Beneficiary Relationship:

2. U.S. Mailing Address

c/o Name: (FirstName LastName)
Address:
City:
State: Zip Code:
Day Phone: xxx-xxx-xxxx
Evening Phone:
xxx-xxx-xxxx
(You must include at least one phone number.)

3. Applicants' Information

 
Insured:
  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
 

4. 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)

5. Plan Selection (Applies to all applicants)

Choose Coverage Level: Budget Standard Superior

6. 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 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 outside my Home Country. I understand this insurance contains a Pre-existing Condition exclusion, a Pre-notification Penalty and other restrictions and exclusions. 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 HCC Medical Insurance Services. 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. 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. Additionally, some licensed producers may also receive bonuses and incentive trips or prizes associated with sales contests based on sales criteria, such as the overall sales volume or for the percentage of completed sales through HCC Medical Insurance Services. Please contact your insurance broker to obtain information about the specific compensation they may receive in connection with the issuance of your 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.

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

7. 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.