Student Information (Items in RED must be filled in)
Student Name:
School:
Street Address:
City:
State:	Postal (Zip) Code:
Phone:	###-###-####    FAX ###-###-####
Student E-mail:	Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#            no dashes
Visitor Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child Parent Uncle/Aunt Grandchild Grandparent Cousin      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY                              VISA Number
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 $500 Deductible $750 Deductible $1000 Deductible Maximum Benefits 18 and Under $ 54 $ 51 $48 $250,000 19 - 40 $ 67 $ 64 $60 $250,000 40 - 49 $ 89 $ 86 $82 $250,000 50 - 59 $ 123 $ 119 $115 $50,000 60 - 69 $ 202 $ 194 $185 $50,000 70 - 75 $ 257 $ 237 $216 $25,000

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