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.