MedjetAssist Motorcycle Rider Program
Enrollment Application
Agency# DC8023
 

SPECIAL NOTE: Please print and complete the following application.
                              This application form is valid for Individual and Family Membership under age 75 only.

*Before submitting an application, please read  Rules & Regulations .

Please make sure your application is legible - Print or Type. Thank you.

Mr.___    Mrs.___   Ms. ___   Dr. ___   Rev.____

Full Name: _________________________________________________________

Address: ___________________________________________________________

City: ___________________________

State:__________________ Zip: ___________

Date of Birth (MM/DD/YY): _____ / _____ / _____

Passport or Driver License Number: ___________________________

Spouse's Full Name: _________________________________________________________

Date of Birth (MM/DD/YY): _____ / _____ / _____

Spouse's Passport or Driver License Number: ___________________________

Family Membership
In addition to yourself, the Family Membership covers your spouse and up to five dependent children under age 19 (or up to age 23 if a full-time student). Please list family members' names and dates of birth.

1. Child: __________________________________________   DOB ____________

5. Child:_______________________________________  DOB ____________

Requested Effective Date:_______________

Phone -Day: (______) _______ - _______

Phone - Evening: (______) _______ - _______

Email Address: _________________________________________________
                           (We will send you confirmation via e-mail.)

Motorcycle Information
VIN Number:______________________              Year:___________
Make:___________________________              Model:__________      Color:__________

Is your Mailing Address the same as the one listed above?  __Yes      __No
Please provide your current mailing address if it's different from your Home Address.
_____________________________________________________________________

Standard Program -- under age 75:
7-Day Travel Protection Plan            __Individual $85.00             ___Family $155.00
14-Day Travel Protection Plan          __Individual $105.00           ___Family $195.00
21-Day Travel Protection Plan         __Individual $135.00            ___Family $245.00
One Year (90 days or less)            __Individual $225.00            ___Family $350.00

Expatriate Program -- under age 75:
Level One (91-180 days)                 ___Individual $380.00           ___Family $485.00
Level Two (181-270 days)              ___Individual $475.00            ___Family $655.00
Level Three (271-One Year)           ___Individual $595.00             ___Family $885.00

(Certain restrictions apply. Your membership in MedjetAssist protects you worldwide when traveling more than 150 miles from your primary residence, except while traveling in countries where U.S. Department of State travel restrictions apply. This membership is nonrefundable and nontransferable. Must be under age 75. Other restrictions may apply. These rates available to those under age 75 and 90 day maximum per foreign trip for Standard Membership. For extended-stay, expatriate or Diamond Plan membership information, for individuals 75-81 years of age, please call 1-877-211-3654.)

Check payable to MedjetAssist.

Mail to:
Sunburst Worldwide Insurance Services
P.O. Box 1016, Clovis, CA 93613
Fax: 559-421-1956
* If you pay by Credit Card, you may fax your application.

Please charge my Credit Card: __ MasterCard  __VISA   __American Express  __Discover Card

Card Number: __________________________________________   Expiration Date: _____ / ____

Name - Exactly as it appears on your Credit Card: __________________________________________
           
I agree to pay above total amount according renewal card issuer agreement.
I declare that I understand the terms and conditions of MedjetAssist Program and
that membership fees are non-refundable.
 

_______________________________________         Application Date:_____________
SIGNATURE

Agency # DC8023

If you have any questions or concerns, please contact us.
info@internationalriskmanagement.com
877-211-3654 or 559-294-0316

Sunburst International Risk Management
Integrity + Experience + Dependability
Mailing address: P.O. Box 1016, Clovis, CA  93613  USA
Phone: 559-294-0316   Fax: 559-421-1956   Email: info@internationalriskmanagement.com
Websites: www.WorldWideMedicalPlans.com    www.InternationalRiskManagement.com