Make sure your relatives have medical insurance when they come to visit!

Any LRFA member may apply for coverage for their adult (over age 18) relative, who is a foreign national, and their dependent children over 14 days old, while on a legal trip to the United States for a period not to exceed 12 months. Coverage must include the entire duration of the visitor’s stay in the United States and be paid in full prior to departure from the individual’s home country.

LRFA Member's Information

Covered Person's Information

Coverage Dates and Plan

Effective date will be the latest of: 1) date of arrival, 2) date requested or 3) date application and premium are received.

Coverage automatically terminates when covered person departs the United States.

Please Select Coverage Plan Please select a plan

Payment For Coverage Due

Person Name Age Monthly Premium
Covered Person
$
Dependent Child
$
Dependent Child
$
Dependent Child
$

Total Monthly Payment

Total Monthly Premium
$
Number of 30 Day Periods
Total
$

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.