Travel Medical Plan Enrollment

The LRFA Travel Medical Plan provides coverage for LRFA Members while traveling outside the United States. Members who are in good health, can be covered for a maximum period of eight(8) months, per year. Coverage is for the entire duration of your trip. When applying, please include both departure and return dates in your total day count.

Your Information

First Name	Please fill out this field
Last Name	Please fill out this field
Membership #	(if not a current LRFA member, annual fee will be added)
Address	Please fill out this field
Address (line 2)
City	Please fill out this field
State/Province	Please fill out this field
Zip/Postal Code	Please fill out this field
Country	Please fill out this field
Telephone	Please fill out this field
E-Mail Address	Please fill out this field
Beneficiary	Please fill out this field
Relationship to you	Please fill out this field

Coverage Dates & Plan

Select the Plan that is right for you. See Benefit Plan options.
Benefit Plan A
Benefit Plan B
Destination Please fill out this field
Departure Date Please fill out this field
Return Date Please fill out this field
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

	Name	Date of Birth	Age	# Days	Payment
Rates: (see pricing) For 1 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)
Individual Coverage
Dependent Name
Dependent Name
Membership & Registration Fee (if not an LRFA member):
Total Payment:

Questions and Comments:

Signature

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.

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