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 (First, Middle, Last): _______________________________________________________________

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

Passport or Driver License Number: ________________________

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

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

Address: ______________________________________________________________

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.

Spouse (First, Middle, Last): ___________________________________________  DOB (MMDDYY) ____________

Spouse's Passport or Driver License Number: _____________________________

1. Child's Full Name: __________________________________________  DOB (MMDDYY) ____________

2. Childs Full Name: ____________________________________________ DOB MMDDYY) ____________

3. Childs Full Name:_____________________________________________DOB (MMDDYY) ____________

4. Childs Full Name:_____________________________________________DOB (MMDDYY) ____________

5. Childs Full Name: __________________________________________  DOB (MMDDYY) ____________

Type of Membership (Please select one)

Standard Program -- under age 75:


(  ) 7-Day Travel Protection Plan*
(  ) 14-Day Travel Protection Plan*
(  ) 21-Day Travel Protection Plan*
(  ) 30-Day Travel Protection Plan*
(  ) Annual Membership Plan		 Individual
$95
$115
$150
$180
$250		 Family
$170
$215
$270
$335
$385

Optional Rider: Motor Cycle Protection: Additional $25.00

(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 or email: info@internationalriskmanagement.com )

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

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 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.
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:
Websites: www.WorldWideMedicalPlans.com    www.InternationalRiskManagement.com