Date Mr. Ms. Yes No Cert.
Coverage is issued according to plan specifications and rates in effect at time of enrollment.
Refund of Premium Full refund of premium is made if written request is received by Gateway Administrator prior to the Effective Date of coverage. Premium is considered fully earned and is not refundable for any term of coverage issued for 6 months or less. If you are issued a Period of Coverage for 7 or more consecutive months, and must return to your Home Country or Country of Residence earlier then expected, unused premium for remaining whole months exclusive of the first 6 months will be refunded. Remaining whole months are calculated from the date written notice is received up to the termination date of the Period of Coverage in effect. Total premium for Full Term of coverage requested must be made in U.S.Dollars at the time application fo coverage is made.