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Accidental Death and Dismemberment Beneficiary (ADDB)

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Coverage will be effective on the Trip Start Date or the date the correct premium is received by INF Health Care indicated above, whichever is later, unless otherwise stated in the Master Policy. It is the Insured's responsibility to timely enroll or re-enroll for coverage. Total Premium due is inclusive of a non-refundable initial INF membership fee of $10 and $5 administration fee or $5 re-enrollment fee . By signing/ checking below, the Insured or their representative acknowledges the following: He/She has carefully read, understands, and agrees to the terms and conditions of the coverage, including limitations and exclusions and elects to enroll as indicated on this enrollment form. He/She meets the eligibility requirements for this coverage as described in the program description and if it is later determined that the Insured is not eligible, the premium will be refunded. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I have read, understood and agree with the cancellation policy as outlined in the Program document on the web. I have read, understood and accepted the terms and conditions of the insurance plan.

Refund of premium, less a $25 processing fee, will be considered only if Cancellation Form is received by the INF Visitor Insurance, LLC prior to the effective date of coverage by 5:00 PM EST the day before coverage starts. After that date, the premium is considered fully earned and non-refundable. Enrolled must attest they did not use INF insurance to obtain any visa nor use for any govermental purpose while cancelling, and absolve INF of any liability for medical expenses while in the United States or abroad and takes full responsibility for all medical expenses.

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