www.isis-travelinsurance.com 

ISIS Incoming to the US Insurance Application

INSTRUCTIONS:  
Please PRINT this form, complete all applicable information and include your PAYMENT.

MAIL

ISIS Health Insurance
 P.O. Box 20069
Alexandria, VA  22320

FAX
If paying by Credit Card you may Fax your completed application to us at: 
1-202- 296-0007

 PHONE
 If you are leaving within 2 weeks, please order by telephone, using a major credit card.  
Please contact us at 1-800- 247-5575 or 1-202-347-7324.   
Your Name:
USA Address:
(Address you can be contacted at while in the USA)
USA Address 2:
City:
State:         Zip Code:
Home Country:
Date of Birth:  (MM/DD/YY)
Home Phone Number:
 (Please include the country code for non-US phone numbers)
Work Phone Number:
E-mail Address:
Passport Number(s):
Effective Date:
(date of departure)		    Expiration Date: 
                        (date of return)
No. of Travel Days:  (Count departure and return days.)
Type of Insurance Plan (choose all that apply): Plan A  Plan B  Plan C  Plan D
To view plan descriptions Click Here
Youth or Student Card Number (if applicable):
Family Members to be Covered: 

(names, ages*, relationship to Applicant)
Emergency Contact Name & Telephone Number:
Name of Beneficiary:
Beneficiary's Relationship to Applicant:
Beneficiary's Address:
Traveling Companion(s):
Hazardous Sports Coverage (optional): YES   (10% extra premium)
Cancellation Coverage (optional): YES   (5% extra premium)
Total Payment for all Travelers:
To view Incoming Premium Schedule  Click Here

_____________________________________________
Select A Payment Method:

Option 1
Send a CHECK or MONEY ORDER with your application made payable to VISIT/ISIS Health Programs.  Please enclose your check or money order with your completed application.

Option 2
To Order by CREDIT CARD, please complete the following information.
Please choose one: MasterCard     VISA     American Express

Print Name as it appears on card:
Card Number:
Expiration Date (month/year):

NOTE:  Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information may be guilty of insurance fraud.

Signature of Applicant                                                          Date
             

 
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