How Do I Apply
[pic]
VISIT® International Health Insurance
EPI J-2 Dependent (Spouse/Child)
Automatic Monthly Payment (AMP)
Enrollment Form
Required for ALL Dependents with a J-2 Visa
You Must ENROLL ALL DEPENDENT(S) FOR AUTOMATIC MONTHLY PREMIUM PAYMENT
Charged Monthly to your Credit/Debit card
1. Dependent’s Name, as it appears on the Passport:
___________________________________________
Date of Birth: ___________ Gender: ___________
2. Dependent’s Name, as it appears on the Passport:
___________________________________________
Date of Birth: ___________ Gender: ___________
3. Dependent’s Name, as it appears on the Passport:
___________________________________________
Date of Birth: ___________ Gender: ___________
HOME COUNTRY ADDRESS: ____________________
_______________________________________________
USA ADDRESS: ___________________________________________
City: _____________________________________
State: _________________ Zip: _______________
Contact Phone# : ____________________________
E-Mail Address: _____________________________
Start Date:
(This MUST be exact date your Dependent(s) ARRIVE in the United States)
MONTHLY PAYMENT WITHDRAWAL DATE
Your credit/debit card will be charged on the same day each month as the Start Date of the policy.
(As an example, if the policy starts on August 1, your monthly payment will be charged to your credit/debit card on the 1st of each month.)
SELECT PAYMENT METHOD:
○MasterCard ○VISA ○American Express
○Discover ○Bank Debit Card
Credit/Debit Card Number
__________________________________________
Expiration Date (month/year): _______________
Security Code: ____________
Name On Card: _____________________________
Billing Address: _____________________________
City: _____________________________________
State:___________________ Zip: ____________
I authorize VISIT® Insurance to automatically charge my Credit/Debit card each month. I understand I must notify VISIT® Insurance 10 days prior to the date of my auto renewal with any changes.
___________________________________________
Full Name of EPI Teacher, as it appears on the Passport
Authorized Signature
Date: _______________________________________
PLEASE EMAIL YOUR COMPLETED FORM TO epi@
OR FAX IT TO (703) 991-9164
The EPI APPROVED Health Plan E PLUS:
$100,000 Medical / $100 Annual Deductible
For more information about the J-2 Health Plan, please go to epij2.html
8-2020
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- how do i calculate a car payment
- how do i sell stocks i own
- when do i apply for fafsa
- how do i do apa citation
- how do you apply for student loans
- when do i apply for student loans
- how do i do a journal entry
- how do i do a print screen
- how do you apply for rent assistance
- how do i do a system restore
- how do i apply for disability benefits
- how can i apply for a housing choice voucher