VISIT TRAVEL & MEDICAL INSURANCE- Application Directions

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VISIT^® Travel & Medical Insurance Program
for International Students, Scholars, Spouses, Families and Visitors

Call Us Today 1-800-247-5575 or 1-703-660-9062 or

The Trusted Name in International Health and Travel Medical Insurance for over 30 Years!

Application Information

Please have the following information available to complete the application process:

	Premium Rates All premium rates are per person.
	Renewing Your Policy If you are RENEWING, please complete the application form and mark Yes for RENEWAL. You may also RENEW over the phone for faster service.
	Applicant Name This is the name of the policy holder.
	Passport Number Please list the passport number of the primary applicant.
	Policy Effective Dates Effective date of the Policy and the Expiration date of the policy. This is the start and end date of insurance coverage you would like for the policy you are currently purchasing.
	Primary Destination Primary Destination is the USA if you are applying for the Incoming to the USA Plans. If you are applying for the Outbound from the USA Plans, please indicate the name of the country you will be traveling.
	Return Destination For the Incoming to the USA Plans, please indicate the country you will be returning to after your stay in the USA. For the Outbound Plans, your return destination would be the USA.
	Emergency Contact Please provide the name of an Emergency Contact & Telephone number.
	Payment If paying by credit card, please have your credit card information ready. VISIT accepts MasterCard, VISA and American Express
	Family Members Please list the name, birth date, gender and relationship to applicant for all Family members to be covered by this policy. Plans are per person.
	Beneficiary Beneficiary name and address. The Beneficiary is the person that would receive the monetary benefit in case of an accidental death of the insurance policy holder.

How Do I Apply?

VISIT Travel & Medical Insurance makes applying easy!

To apply, please choose one of the following options:

YOU MAY ORDER BY:
Online Phone Fax or Mail
_______________________

Buy Online Now using a major credit card. (MasterCard, VISA, American Express)
This process will take approximately 5-7 minutes to complete over our Secure Server.

If you experience any difficulty with applying online, please contact our office at 1-800-247-5575 and we will be happy to take your application by phone.

If you are RENEWING your application, please complete the online order form and check
YES to the question- Is this a Renewal?
_________________________

Option 2 - Order by Phone

Phone orders only take a few minutes to complete and our representatives will be pleased to answer any questions you may have. Please have your credit card (MasterCard, VISA or American Express) information available as well as the names, birthdates and passport numbers of all family members to be covered. Please have the specific dates of coverage and beneficiary information available when placing your order.

Please contact us at:
1-800-247-5575 or 1-703-660-9062

VISIT Travel & Medical Insurance representatives are available during regular business hours:
Monday-Friday, 9:00 a.m. to 6:00 p.m.
USA Eastern Time
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Print Application
To view and print an application in .pdf format Click Here

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Once you have completed the application, please Mail or Fax it to:

By Mail:
VISIT Travel & Medical Insurance
PO Box 210
Mount Vernon, VA 22121

You may pay by check, money order or major credit card if mailing your application to VISIT. Your application is NOT valid until it is received by VISIT. Consider ordering online for immediate coverage and confirmation.

By Fax:
1-703-991-9164 FAX

You MUST use a major credit card to submit your application by fax.

Cancellation Policy
All premiums are fully earned upon Application, and are Non-Refundable. Please apply only for the term of coverage you need, and re-apply as necessary as your plans may change.

VISIT Travel & Medical Insurance Program, an Insurance program of PENTECO, LLC
www.visitinsurance.com
Correspondence: P.O. Box 210, Mount Vernon, VA 22121 (703) 660-9062/ (800) 247-5575/ (703) 991-9164 fax
email: info@visitinsurance.com

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