Quote Page

Quote Summary

Option

Coverage start date

Number of travelers

Country of residence

Country of destination

Total to pay US $

Main Applicant

First and last name

Address**

City**

Postal code*

Email address

Date of birth

Gender**

Language**

Telephone**

Passport number

Travel Companion(s)

Restrictions

War zone

We will only offer coverage in Iraq and Afghanistan if we have provided prior approval. Please contact us if you are planning to travel to one of these countries.

Any approved coverage will incur in an additional premium.

Expeditions

The policy does not cover expeditions, mountaineering and trekking in Antarctica, the North Pole and Greenland; or mountaineering or trekking that requires the use of specialized equipment, regardless of where this activity might occur.

If you have any questions, send your itinerary (travel description) to travelvip@vumigroup.com.

Declaration of Pre-Existing Conditions

Section l. Applicant Information

Name:

Last name:

Date of birth

Genero

Male Female

Address

City

State

Postal code

Country

Email address

Destination(s)

Telephone

Fax

Departure date

Return date

Section ll. Medical Information

Diagnosis

Date of diagnosis

Treatment type and scope

Hospitalization or other medical treatment for the pre-existing condition or its complications within six months of the departure date

Ongoing medical treatment or change in medication within six months of the departure date

Anticipated check-ups or additional treatment

Yes No

Anticipated treatment type and scope

Date of anticipated treatment

Others

Section lll. Certification and Authorization

I certify that I have read and reviewed all answers and statements in this form and that, to the best of my knowledge, the information is complete and correct. I understand that any omissions, incomplete statements, or incorrect answers may result in the delay or denial of this claim.

I hereby authorize VUMI® or VUMI® Group, I.I., its subsidiaries and affiliates to request my medical records and/or those of my dependents or travel companions, as well as any prescription drug history and any other medical or pharmaceutical information to be considered in the claim process for myself, my dependents or travel companions. I authorize any physician, hospital, laboratory, pharmacy or other medical provider, health plan, insurer, the Medical Information Bureau (MIB), or any other organization or person, including any family member who has medical records or knowledge of me or my health to disclose such

information, or any other information required to process this claim, to VUMI® or VUMI® Group, I.I. or its designated representatives. Likewise, I hereby authorize VUMI® or VUMI® Group, I.I. and its subsidiaries and affiliates to disclose to my agent/insurance agency, affiliates, successors and the Medical Information Bureau (MIB) the terms of my policy, my certificate of coverage and other insurance documents, payment information, claims, reimbursement requests and medical records that may contain protected health information that will enable them to address my questions and facilitate interaction regarding my insurance coverage and claims payments. I understand that there is a possibility of re-disclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality.

Acknowledgement and Authorizations

Authorization to collect and disclose information about my health

Privacy

Electronic Signature Agreement

Consent to electronic delivery

OFAC

Updating your contact details

You are responsible for ensuring that we have your current email address in order to receive Electronic Communications.

The main applicant agrees with the above.

Recognition of the agent:

As Agent, accept full responsibility for delivering this application and all premiums collected to VUMI GROUP, I.I.., as well as deliver the policy to the applicant when it is issued. I do not know of any information that has not been declared in this application, which will affect the insurability of applicants.

As an agent - , I agree all of the above.

Credit Card Details

Credit card number**

Expiration date**

CVC**

Email address*

Cardholder's name**

Cardholder's last name**

Postal code*

Telephone*

Address*

IMPORTANT:
-The fields marked with ** are required
-The fields marked with * are recommended

Automatic debit for future renewals:

Yes No

information, or any other information required to process this claim, to VUMI® or VUMI® Group, I.I. or its designated representatives. Likewise, I hereby authorize VUMI® or VUMI® Group, I.I. and its subsidiaries and affiliates to disclose to my agent/insurance agency, affiliates, successors and the Medical Information Bureau (MIB) the terms of my policy, my certificate of coverage and other insurance documents, payment information, claims, reimbursement requests and medical records that may contain protected health information that will enable them to address my questions and facilitate interaction regarding my insurance coverage and claims payments. I understand that there is a possibility of re-disclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality.
In the event that a direct debit is, for any reason, rejected or denied, I accept that I have a personal responsibility to immediately pay the premiums of my travel insurance policy or the policy may be rescinded, suspended or canceled. I authorize automatic deductions for future annual renewals.

Electronic Check

Add a copy of the check

Bank Name**

Routing Number (ABA)**

Routing number confirmation (ABA)**

Account number**

Account number confirmation**

Holder Name**

Account holder type**

Account type**

APPLY AND PAY FOR ANNUAL TRIP COVERAGE