ENROLLING IN LIAISON INTERNATIONAL

  1. Complete the entire Liaison International Application. Payment for the entire period of coverage is due at the time of application.
  2. If paying by check or money order, make payable to: "SRI" and enclose it together with completed Application.
  3. If paying by credit card, complete the Application and mail or fax to Insurance Services of America.  Be sure to sign Method of Payment section.
  4. Read the brochure and sign the application.

Return the Application with your payment for the total payment to:
INSURANCE SERVICES OF AMERICA
1757 E. Baseline Rd, Ste 126
Gilbert, AZ  85233
Fax 480-821-9297
Phone: 800-647-4589 / 480-821-9052
Email: health@worldwidemedical.com  
(You may fax if paying by credit card only. Originals are not required if application is faxed to Insurance Services of America with credit card payment.)

MONTHLY AND DAILY RATES
Rates Based on a $250 Deductible.
Effective until December 31, 2005

For those Traveling to the United States
(If the applicant is traveling to, temporarily residing in, or visiting the United States, please use these rates.

For those Traveling Outside the US
(If the applicant is traveling outside the United States, use these rates.   This includes US citizens traveling overseas as well as persons traveling between countries.  ie. a Brazilian traveling to Spain

 
Policy Maximum Options
Age
$50,000
$100,000
$500,000
$1,000,000
  Monthly/Daily Monthly/Daily Monthly/Daily Monthly/Daily
19 to 29
$48/1.60
$56/$1.87
$76/$2.53 $85/$2.83
30 to 39 $63/$2.10 $74/$2.47 $99/$3.30 $110/$3.67
40 to 49 $95/$3.17 $106/$3.53 $145/$4.83 $160/$5.33
50 to 59 $134/$4.47 $163/$5.43 $195/$6.50 $230/$7.67
60 to 64 $160/$5.33 $201/$6.70 $249/$8.30 $285/$9.50
65 to 69 $205/$6.83

 N/A

N/A

N/A

70 to 79 $258/$8.60 N/A N/A N/A
80 plus* $258/$8.60 N/A N/A N/A
Each Dep. Child $28/$0.93 $32/$1.07 $42/$1.40 $45/$1.50
Each Child Alone $46/$1.53 $54/$1.80 $68/$2.27 $76/$2.53
 
Policy Maximum Options
Age
$50,000
$100,000
$500,000
$1,000,000
Monthly/Daily Monthly/Daily Monthly/Daily Monthly/Daily
19 to 29
$32/$1.07
$38/$1.26 $42/$1.41 $47/$1.57
30 to 39 $38/$1.26 $44/$1.45 $56/$1.86 $64/$2.12
40 to 49 $61/$2.02 $68/$2.28 $73/$2.43 $81/$2.69
50 to 59 $100/$3.33 $114/$3.80 $122/$4.05 $129/$4.30
60 to 64 $114/$3.80 $136/$4.53 $149/$4.95 $168/$5.59
65 to 69 $133/$4.44 $145/$4.85 $153/$5.10 $174/$5.79
70 to 79 $199/$6.62 $280/$9.34 N/A N/A
80 plus* $333/$11.09

N/A

N/A N/A
Each Dep. Child $20/$0.67 $25/$0.83 $27/$.90 $30/$1.01
Each Child Alone $32/$1.07 $36/$1.21 $40/$1.32 $43/$1.44
* Ages 80+ limited to $15,000.  Dep. Child rate is applicable when at least one parent will also be covered under Liaison International.   Child Alone rate is used when a child will be insured by themselves.

            Premium           35-year-old U.S. citizen traveling to Spain , from March 15th to April 19th 
            Example:          $250 deductible and $50,000 maximum

                                   
March 15th through April 14th equals 1 month (calendar month)       $38.00
                                   
April 15th through April 19th equals 5 days $1.26 x 5                      $  6.30

                                   
Total Premium Submitted                                                            $44.30


INSURANCE CARRIER
Virginia Surety Company, Inc
Rated A- "Excellent" by A.M. Best
(For addresses in the following states, the program is underwritten by Certain Underwriters at Lloyd's, London. Special States: NY, OR, KS)

 


LIAISON International APPLICATION 2005
Effective until December 31, 200
5
OFFICIAL USE ONLY: Cert#: Processed: Eff Date: Agent:1567

Applicant Information  

Last Name: _________________________________________

 First Name: _______________________________ M.I.______

 Country of Permanent, fixed Residence (Home Country) __________

 Passport Number / Country:____________________________

 Departure Date from your Home Country? (MM/DD/YY) ____ / ___ / ____  

AD&D Beneficiary: _____________ Relationship: ___________
(Accidental Death & Dismemberment)
 

Address of Correspondence  
(where ID card is to be sent)
 

Name: _____________________________________________

 Address: ___________________________________________

 City: _______________________________ State : __________

 Postal Code: _____________  Country: __________________

 Work Phone: (       ) __________ Home Phone: (       ) ____________

 Email: ______________________________________________

 Previously insured by SRI? ______ ID Number: ____________

 When would you like coverage to begin? (MM/DD/YY) ____ / ____ / ____

 Destination?: ___________________ Length of Trip?: _______

 What is your expected return date? (MM/DD/YY) ____ / ____ / ____

 Please note:  The minimum period of coverage is 5 days, the maximum is 12 months (please see Continuing Coverage Option). Coverage must be purchased in increments of no less than 5 days. Coverage cannot begin until your departure from your Home Country, nor will coverage begin until SRI receives and accepts your application and correct payment.

 Coverage Specifics

 Are you traveling:¨ To the United States  ¨ Outside the United States

Policy Maximum:      ¨ $50,000  ¨ $100,000 
        ¨
$500,000 ¨ $1,000,000

Deductible:               Option                      Factor
                               
¨ $0                       1.30
                               
¨ $100                   1.10
                               
¨ $250                   1.00
                               
¨ $500                     .90
                               
¨ $1000                   .80
                               
¨ $2500                   .70
Continuing Coverage Option:
¨ No  ¨ Yes  (must buy at least 3 months)
Coverage Option:   
¨ Hazardous Sport Coverage (1.15)

Calculating Your Plan Cost 
(please complete entire section)

 

Date of Birth

MM/DD/YY

Monthly Rate

 

Daily Rate

Applicant: _____________________

__/___/___

 

 

Spouse: ______________________

__/___/___

 

 

Child: ________________________

__/___/___

 

 

Child: ________________________

__/___/___

 

 

Child: ________________________

__/___/___

 

 

 

Total:

$

$

Minimum period of coverage is 5 days

Multiply Monthly Rate Total by number of months:

X

 

Monthly Total [A]:

$

Multiply Daily Rate Total by number of days:

X

 

 Daily Total [B]:

$

Total of [A] and [B]:

$

Multiply by deductible factor:

X

 

 

Total:

$

Multiply coverage Option Factor: (if applicable)

X

 

Total Payment Enclosed:

 

$

  Method of Payment
¨
Check  ¨ Money Order  ¨ MasterCard  ¨ Visa  ¨Discover
¨
American Express  
Card Number: _______________________________________
 

Expiration Date: ______________ Day 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(checks must be issued from a U.S. bank) 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 understand the terms and conditions of this product, as outlined in this brochure. I understand that pre-existing conditions, as defined in Exclusion number 1, are excluded.  I understand this program is for persons traveling outside their home country.  

I hereby subscribe to the American Consumer Insurance Trust and enroll in the group coverage for which I am eligible under the group contract issued by Virginia Surety Company, Inc. (For Special States, it is the Global International Trust by Certain Underwriters at Lloyd’s, London).

__________________________________________________
Signature of Insured or Proxy (Required)               Date

(Proxy is someone acting on behalf of the Insured)

Liaison® is a registered Trademark of Specialty Risk International, Inc.
In Florida, Florida Resident - Agent No. A10702