International Medical Travel Insurance and Services - Enrolment Application

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General Information

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This is not a medical policy. Eligible claim expenses would be submitted for approval and reimbursement to the claimant. Benefits are excess of any other valid and collectable coverage. A covered complication must occur and be separately diagnosed within 180 days of the elective procedure / treatment date.

All insurance limits and enrolment costs are indicated in ($) US Dollars.

Please review the following options and select your limit choice.

Maximum Sum Payable for Certain Benefits * These benefits indicated are subject to a maximum sum payable. A single claim may trigger more than one of these benefits, however when combined, the benefit payable is the total of the claim or the maximum sum payable, whichever is less.	Option 1	Option 2	Option 3	Option 4
	$25,000.00	$50,000.00	$75,000.00	$150,000.00
MEDICAL TOURIST / TRAVELLER - MEDICAL COMPLICATIONS COVERAGE
*Accidental Death or Dismemberment	$0.00	$0.00	$0.00	$0.00
Repatriation of Mortal Remains	$0.00	$0.00	$0.00	$0.00
*Additional Medical or Surgical Treatment (AMST) - Covered Complications	$0.00	$0.00	$0.00	$0.00
*The above AMST limit is excess of:	$0.00	$0.00	$0.00	$0.00
*Additional Medical or Surgical Treatment for Unsuccessful or Unfavorable Outcomes as a result of a Covered Complication	$0.00	$0.00	$0.00	$0.00
*Additional Medical or Surgical Treatment due to a Thrombosis	$0.00	$0.00	$0.00	$0.00
*Additional Expense - Travel, Meals, and Accommodations as a Result of a Covered Complication (Additional costs of meals and accommodations limited to $250 per diem and additional costs of Travel equal to the same class of travel initially booked).	$0.00	$0.00	$0.00	$0.00
*Travel Companion Coordination as a Result of a Covered Complication (Additional costs of meals and accommodations limited to $250 per diem and additional costs of travel equal to the same class of travel initially booked).	$0.00	$0.00	$0.00	$0.00
Emergency Medical Transportation	$0.00	$0.00	$0.00	$0.00
24 Hour - Emergency Medical Assistance Service Medical emergency assistance service, available 24/7/365 to assist participants in the event of a medical emergency. This service can direct ill or injured persons to the nearest facility for treatment, including arranging of medical evacuation, companion coordination and other needs.
MEDICAL TOURIST / TRAVELLER - TRAVEL BENEFITS The below are additional coverages but exclude medical complications.
Emergency Medical Coverage - (Accident and Illness) Limit excess of $250	$ 0.00
Travel Cancellation in Exceptional Circumstances	$ 0.00
Travel Delay + 12 hours (Outbound Only)	$ 0.00
Loss of Baggage (Outbound Only) Limit excess of $250	$ 0.00
Insurance and Services Cost - Medical Traveller	$0.00	$0.00	$0.00	$0.00
*Crisis24 - Horizon Mobile (Travel App)	$0.00	$0.00	$0.00	$0.00
Total Cost including Medical Traveller, Companions (if any) and SARS-CoV-2 (if applied)	$0.00	$0.00	$0.00	$0.00
SELECT - Your Choice of a Maximum Sum Limit	$25,000.00	$50,000.00	$75,000.00	$150,000.00

Included in your enrolment is Horizon Mobile, (by Crisis24) a wide range of travel security advice and assistance services designed to help with safety and risk minimization, including lost or stolen passport assistance. The app includes location intelligence, alerts, quick connect assistance buttons, advice sheets and useful links. This app is available on Android and iOS. Your Member ID is available when you log into your account. The details are provided on your Confirmation of Coverage.

If you need to amend or make corrections to previously submitted information, do not use your browser back / forward buttons. This may result in data loss. Please use the blue navigation buttons towards the top of the page. You must resubmit each page before proceeding to the next by clicking the submit button at the bottom of each page.