VISIT Travel & Medical Insurance Application
www.visitinsurance.com

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

MAIL

VISIT Travel & Medical Insurance
P.O. Box 210
Mount Vernon, VA  22121

FAX

If paying by Credit Card you may Fax your completed application to us at: 
1-703-991-9164
Name:
Address: (Please indicate an address in the US)
Address 2:
City:
Country:      Postal Code: 
Date of Birth:    (MM/DD/YY)    Gender of Applicant 
Home Tel:     Work Tel:
E-mail Address:
Passport Number(s):
Policy Effective Date:
 		    Policy Expiration Date:    Renewal? Yes No
                         
Number of Coverage Days:  (Count policy effective date and policy expiration date.)
Type of Insurance Plan:
(choose all that apply)		 Plan A  Plan B  Plan C  Plan D  Plan E
To view plan descriptions Click Here
Family Members to be Covered on this policy: 

 * Premiums are per person

(names, dates of birth (MM/DD/YY), gender, relationship to Applicant)
Emergency Contact Name & Telephone Number:
Beneficiary:
Beneficiary's Relationship to Applicant:
Beneficiary's Address:
Payment for all Travelers:
To view Premium Coverage Click Here

Maximum policy term is 12 months, but you may re-enroll for successive terms, as desired. Applicant must meet application criteria and all conditions and pre-existing exclusions apply.
* Premium rates listed on this website are for persons traveling abroad and their family members traveling with them, 69 years of age and younger. Additional coverage is available for persons 70-80 years of age. Please call 1-800-247-5575 for premium rates or Click Here for additional program options.

 Cancellation Policy
All premiums are fully earned upon Application, and are Non-Refundable. Please apply only for the term of coverage you need, and re-apply as necessary as your plans may change.

Select A Payment Method:

Option 1
Send a CHECK or MONEY ORDER with your application made payable to VISIT.  Please enclose your check or money order with your completed application and mail to: VISIT- PO BOX 210, Mount Vernon, VA  22121.

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):
Billing Address:
Billing Zip Code:

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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