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 MCIS Multichoice Insurance Services

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Coverage will be effective on the date the correct premium is received by INF Health Care or the effective date of the coverage period 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 non-refundable $15 administration fee. By signing/ checking below, the Insured or their representative acknowledges the following:He/She has carefully read, understand, and agrees to the terms and conditions of the coverage, including the pre-existing condition limitations 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. He/She understand that the Pre-existing coverage is subject to approval if the plan is purchased after the visitor arrives in the United States. He/She understands that when enrolling using the Corporate Rates Plan, he/she waive any right to refund after the purchase date. If it is later determined that the Insured is not eligible, the premium will be refunded. I have read, understood and accepted the terms and conditions of the insurance plan. 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.

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