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.
Membership Benefit Plans About Us Forms Contact Us
Information Request Form
Membership
Change of Address
Benefit Plan Enrollment
Travel Plan Enrollment
Benefit Claims
Make a Payment

Travel Medical Plan Enrollment Form

See your Benefit Plan options.
If you are not already an LRFA member, please complete form F-48(a). Your membership payment can be added to this enrollment form to avoid delays in your Travel coverage. Confirmation email will be sent to you once we receive this form.

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

Your Information
First Name
Last Name
Middle Initial
Membership # (if current member) Passport #
Address
Address (line 2)
City
State/Province
Zip/Postal Code
Country
Telephone
E-Mail Address
Family Doctor's Name 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

Effective date will be the latest of: 1) date of departure, 2) date requested, or 3) date application and premiums are received.
Destination  
Departure Date   Return Date  
Maximum coverage period is 8 months. Coverage automatically terminates when covered person returns to the Home Country.

Calculating your Payment
Rates:
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
Covered Adult
Dependent Child(<18)
Dependent Child(<18)
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.

 

 

© 2016 LRFA   -   P.O. Box 8857, Elkins Park, PA 19027-0857   -   info @ lrfa.org

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