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.

Google Online Preview   Download