Student/Graduate Information (Items in RED must be filled in)
Student Name:
School:
Street Address:
City:
State:	Postal (Zip) Code:
Phone:	###-###-####    FAX ###-###-####
E-mail:	Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     F1/J1 Visa # no dashes
Billing Information (Items in RED must be filled in)
Name:
Street Address:
City:
State:	Postal (Zip) Code:
Phone:	###-###-####
FAX:	###-###-####
Your E-mail:
Credit Card Information
Credit Card:	(No spaces or dashes)      EXP DT: (MM/YY) We accept  VISA/Mastercard
Card ID #:

Select the appropriate International Visitor Plan

Monthly Premiums w/ Deductibles AGE $250 Deductible $500 Deductible 30 Days - 20 yrs $ 93 72 21 yrs - 25 yrs $ 55 $ 44 26 yrs - 30 yrs $ 58 $ 51 31 yrs - 35 yrs $ 61 $ 56 36 yrs - 40 yrs $ 71 $ 60 41 yrs - 45 yrs $ 104 $ 90 46 yrs - 50 yrs $ 142 $ 127 51 yrs - 59 yrs $ 223 $ 187

Effective Date :	Please enter the date you would like coverage to begin
Other Questions, Comments, or Requests: