Get covered and relax on your trip

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
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.