LRFA

Latvian Relief Fund of America


LRFA is a professionally managed, non-profit, mutual assistance organization, designed to provide our members with affordable health care plans and financial assistance in emergencies. We support other Latvian-American organizations and education in the U.S. and abroad.
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Information Request Form
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Change of Address
Benefit Plan Enrollment
Travel Plan Enrollment
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Travel Medical Plan Enrollment Form

sunSUMMER SPECIAL FOR NEW MEMBERS!!!
Non-LRFA members who enroll in the LRFA Travel Medical Plan before August 1, 2018 save $20 off the enrollment fee! (children under 18 save $10)
If you are not a current LRFA member,your membership enrollment will be added to this form to avoid delays in your Travel coverage. Confirmation email will be sent to you.

Current LRFA Members sign up today with no registration fees and get low 2017 rates!

Please provide the following information: ( Red indicates a required field)

Your Information
First Name
Last Name
Membership # (if not a current LRFA member, annual fee will be added)
Address
Address (line 2)
City
State/Province
Zip/Postal Code
Country
Telephone
E-Mail Address
Beneficiary
Relationship to you
Coverage Dates & Plan
Select the Plan that is right for you. See Benefit Plan options.
Benefit Plan A 
Benefit Plan B 
Destination    
Departure Date     Return Date    
Effective date will be the latest of: 1) date of departure, 2) date requested, or 3) date application and premiums are received. 
Maximum coverage period is 8 months. Coverage automatically terminates when covered person returns to the Home Country. 
Calculating Your Payment

Rates: (see pricing)
For 01 to 15 day travel: 15 day rate applies
For 16 to 30 day travel: 30 day rate applies
For 31 to 45 day travel: 15 day rate + 30 day rate applies
For 46 to 60 day travel: 2 x 30 day rate applies
(include both the departure and return dates in your total day count)

  Name Date of Birth Age # Days Payment
Individual Coverage
Dependent Name
Dependent Name
Membership & Registration Fee (if not an LRFA member):
On-line payment fee
Total Payment:

Questions and Comments:

By submitting this form, I agree to all the terms of the LRFA Travel Medical Plan. I understand that this is not a general health insurance, and that it is intended for use in the event of a sudden and unexpected sickness or accident. I understand that pre-existing conditions are not covered and all expenses must be authorized by a licensed physician or an accredited medical facility. LRFA Regulations & Limitations apply and are available upon request.

 

© 2017 LRFA   -   P.O. Box 8857, Elkins Park, PA 19027-0857   -   info @ lrfa.org

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