Mr. Ms.     Last Name:
First Name:
Initial:
Home Country Address:
             
             
City/State:
Postal Code/Zip Code:
Country:

Purpose of Trip: Holiday Vacation Visit Family/Friends
Other, please specify:
Most recent date of arrival in U.S.: (month/date/year)
(Proof of Arrival Date may be required, i.e. copy of passport/date of entry stamp or copy of ticket - if convenient you may attach such proof now with the application.)

Passport Number:
Visa Type:
Passport From Country (Applicant):
Passport From Country (Spouse/Child):
Beneficiary:
Relationship:
  (You will be the beneficiary for your spouse and dependent children)
If this plan is available through your professional association, please indicate Name of Association:
Address in U.S.A.for Correspondence:
Name:
Address:
              
City:
State:     Zip Code:
Work Phone:
Home Phone:
Have you been insured by us before ? Yes   No
If yes, then Certificate No.
Premium, Eligibility Criteria, Plan Benefits, Limitations and Exclusions are subject to change. Coverage is issued according to plan specifications and rates in effect at time of enrollment.

Requested Effective Date of Coverage:
(month/date/year)

Requested Term of Coverage: 15-Day Plan or months

Note: 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 six months or less. if you are issued a term of coverage for seven or more consecutive months, and must return to your home country earlier than expected, unused premium for whole months that remain from the date we received your written notification will be refunded.

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