I hereby certify that I have fully read, understand, and agree to the InterMedical Insurance Brief Outline of Coverages and Premium Per Insured Person Rate Chart . The group policy provides limited medical expense benefits for pre-existing conditions. After the effective date of coverage, the premium is considered fully earned and non-refundable. In calculating your premium be sure to include both your departure and return dates. Coverage cannot be purchased after your departure from the U.S. 5.
Coverage purchased by credit card is subject to validation and acceptance.
All Payments must be on a U.S. dollars drawn on a U.S. bank. To effect coverage, the application must be received by Travel Insurance Services by mail or fax. If leaving within 10 days, fax us the application for enrollment. Read and understand the InterMedical Insurance Plans and Benefit Limits and Brief Outline of Coverages as well as the Premium Per Insured Person Rate Chart before applying for coverage. Print the application and complete hard copy.