International Travel 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 Person				1 - 15 16 - 30 31 - 45 46 - 60 61 - 90 91 - 120 121 - 150 151 - 180 181 - 210 211 - 240
Dependent Child				1 - 15 16 - 30 31 - 45 46 - 60 61 - 90 91 - 120 121 - 150 151 - 180 181 - 210 211 - 240
Dependent Child				1 - 15 16 - 30 31 - 45 46 - 60 61 - 90 91 - 120 121 - 150 151 - 180 181 - 210 211 - 240
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 International Travel 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.