Inbound Immigrant Application - 2002
Official Use Only: Cert# Processed: Eff. Date: Agent: 1586
Rates Effective July 1, 2002
All sections must be completed. Incomplete applications will be returned to the applicant without coverage.

Applicant Information

Last Name:
First Name:
U.S. Correspondence Address:
Name:
Address:
City: State:
Postal Code: Country: USA
Daytime Phone Number: ( _____ ) Email:
AD&D Beneficiary: Relationship:

 

Passport & Travel Information

Passport Number:
Country Issuing Passport:
When did or will you arrive in the United States? (MM/DD/YY) ____ / ____ / ____
When would you like coverage to begin? (MM/DD/YY) ____ / ____ / ____
Note: This program is not available to United States Citizens. Your coverage must begin within twenty four (24) months of your arrival in the United States. The minimum period of coverage is 1 month, maximum is 12. If 3 months or more of premium is sent, an automatic renewal notice will be sent to the address above. Total program length available is 60 months. Coverage cannot begin until you depart from your Home Country and SRI both receives and accepts your application and correct premium.

Coverage Requested

Have you purchased insurance through SRI before? [ ] Yes [ ] No If Yes, ID Number:
Selected Medical Policy Maximum: [ ] Plan A - $50,000 [ ] Plan B - $100,000
Selected Per Injury / Sickness Deductible: [ ] $75 or [ ] $150 (70 and over is $250)

Inbound Immigrant Premium Calculation

Name of Persons to be Insured:
Date of Birth
MM/DD/YY
Monthly Premium
Applicant:    
Spouse:    
Child:    
Child:    
Child:    

Total: [A]

  
Multiply by number of months
X
  
Total:
 $
Administrative Fee (required)
+
  $10.00
Total Payment Enclosed:
 $

 

Method of Payment - please check your payment method

[ ] Check [ ] Money Order [ ] MasterCard [ ] Visa [ ] Discover
Card Number:
Expiration Date: Daytime Phone:
Name on Card:
Billing Address
Signature (Required):


Make Check or Money Order payable to "SRI". Total payment for the Full Term of coverage requested must be paid in U.S. dollars at the time application for coverage is made. Coverage purchased by credit card is subject to validation and acceptance by the credit card company.

I declare that I agree and I agree to read and understand the terms and conditions of this product as outlined in this brochure and the program summary, including coverage is not available to any U.S. citizen. I understand that pre-existing conditions, as defined in this brochure, are not covered. I understand that this is not a general health insurance product, but a limited benefit program designed to provide basic benefits under certain circumstances.

I hereby subscribe to the AIG Life Trust and enroll in the group coverage for which I am eligible under the group contract issued by The Insurance Company of the State of Pennsylvania, a member of the American International Group, Inc (AIG). As signatory, I declare that I am affirming all statements for all persons listed on the application (and declare that I have the authority to do so).

____________________________________________________
Signature of Insured or Proxy (Required) ......... Date Signed

 

Inbound Immigrant, Copyright 2002, Specialty Risk International, Inc.(SRI)
"Inbound" is a service mark of SRI