Name: HealthCare America
SKU: 2179
Availability: InStock

ID-Number

HEALTHCARE AMERICA APPLICATION

Name*

First Last

Country of Residency*

You must reside outside the U.S. for this health care plan.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

International Dialing Code

Phone / Cell

Is it is okay to send text messages to this phone number?*

Yes
No

Email*

Enter Email Confirm Email

Date of Birth*

Must be age 3 years to 70 years

Hidden - Date Of Arrival In US

Desired Effective Date*

Last Day of Coverage*

10 - 184 days of coverage allowed

Hidden - Age of Applicant on Coverage Start Date Calculation

DO NOT DELETE THIS FIELD - it is used to calculate the age of the applicant on coverage start date, however, since it does not pass to cart correctly, it's value is copied to the "Age of Applicant on Coverage Start Date" field and that field is used. The copied value passes to the cart correctly.

Hidden - Age of Applicant on Coverage Start Date

Number of Days Coverage*

Is applicant currently under medical care?*

Yes
No

Please explain Current Medical Care*

Emergency Contact

Name

Relationship to Applicant

International Dialing Code

Phone Number

Premium

Ages 3-60	Ages 61-70	Ages 71-75
$9.45	$18.90	Contact Wallach & Company, Inc.
+ $15.00 enrollment fee		Contact Wallach & Company, Inc.

Premium (age 3-60)*

Price: $0.00

Premium (age 61-70)*

Price: $0.00

Enrollment Fee*

Price: $15.00

Total

$0.00

Declaration of Applicant

By clicking the "Continue" button below, I hereby apply to purchase the insurance and I consent to the collection, use and disclosure of my personal information in connection with HealthCare America for the purposes outlined in the Privacy Policy. If I do not consent to the collection, use and disclosure of my personal information in connection with the Privacy Policy, I understand that I will not be able to purchase the HealthCare America policy. I declare to the best of my knowledge and belief that the information given in this Application is true and complete. I acknowledge (on behalf of the person(s) to be insured) that benefits will not apply to treatment arising from pre-existing medical conditions. It is agreed that this declaration and the information given herein shall form the basis of the contract between the Insured Person and the Company. Further, I hereby subscribe to the International Sojourners Insurance Trust and acknowledge enrolling in this group coverage for which I am eligible under the contract issued by the Company.

By submitting this Application you agree to the terms of the Applicant Declaration.

Your insurance documents will be sent to the email address supplied with this enrollment form.

HealthCare America

HealthCare America

HEALTHCARE AMERICA APPLICATION

Emergency Contact

Premium

Declaration of Applicant

CONTACT INFORMATION

DISCLAIMERS