MedjetAssist Program
Enrollment Application
Agency # DC8023

SPECIAL NOTE:
1) Before submitting an application for this plan, please read the Rules & Regulations carefully.
2) To complete this application, please print this application to your printer.
3) This application form is valid for Individual Standard and Expatriate Programs only.
If you are between age of 75 and 85, please contact us for a different application form.

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

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

Full Name: _______________________________________________________________

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

Requested Effective Date (MM/DD/YY): ___________________

Requested Expiration Date (MM/DD/YY): ___________________

City: ___________________________

State: ______________     ZIP: ___________

Phone -Day: (______) _______ - _______

Phone - Evening: (______) _______ - _______

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

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. Spouse: __________________________________________  DOB (MMDDYY) ____________

5. Child:_______________________________________  DOB (MMDDYY) ____________

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. These rates available to those under age 75 and 90 day maximum per foreign trip.
For extended-stay, expatriate or Diamond Plan (for individuals 75-85 years of age) membership information,
please call 1-877-211-3654)

Payment Information

Make 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.
(Our fax machine is ready to accept your application 24/7.)

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

I agree to pay above total amount according renewal card issuer agreement.
I declare that I understand the terms and conditions of MEDJET Assistance Program, as outlined in the brochure and that membership fees are non-transferable and 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