Premium Rates for Gateway VisitAmerica

Adult Rates: 15 Days only (1)  Monthly
Age: 18-29 $30 $49
Age: 30-39 $38 $64
Age: 40-49 $55 $92
Age: 50-59 $75 $126
Age: 60-69 $93 $155
Child Rates:    
Each Dependent Child $16 $26
Each Child Alone (2) $25 $42
$100,000 Additional AD&D (Optional) (3) $9 $14

(1) Minimum Period of Coverage is 15 days, maximum is 6 months. For any term of coverage more than 15 days, full Monthly rates apply. The 15-day term cannot be combined with full month term on the same Application form.
(2) Use these rates for child(ren) who are insured independently and are not included with parent(s) on this Application.
(3) Available only to persons 18 or older.


How to enroll:
If paying by check or money order, enclose check with completed Application and mail to the Gateway Plan Administrator. If paying by credit card, you may either mail or fax your application to: (please don't mail and fax your Application.)

Exec Relo USA
Gateway Plan Administrator
123 East 54th Street, Suite 5H
New York, NY 10022
Tel: (212) 752-0999 or 1 888 BENEFTS(236-3387)  Fax: (212) 752-0791

You must enroll within 7 days of arrival in the United States; proof of arrival date may be required.

Calculating Your Premium
( use form below and enter Premium Rates from chart at above)

Names of person(s) to be insured Date of Birth (mm/dd/yy)  
Applicant     $
Spouse     $
Child     $
Child     $
Child     $

$100,000 Additional AD&D(Optional benefit. If purchased, must be included for both Insured and Spouse, if applicable).

$___________________  x  (Number of adults) = $______________
Total Base Monthly Premium(s) $______________
Multiply by Number of Months*  x ______________
*(Only whole numbers, no fractions of months. If 15 Day plan, enter 1 here)

Total Premium Enclosed $______________

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 American International Group, Inc. (AIG)

Signature of Applicant or Proxy                                           Date


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