By clicking on the Buy Now button, I on behalf of myself and each traveler requesting coverage apply for the travel insurance plan as described. I wish to pay the premium for each traveler requesting coverage by credit card. If the enrollment is accepted, the credit card will be billed for the plan cost. By signing and submitting this enrollment, the person submitting the enrollment represents and warrants that he/she has the cardholder’s authorization to use the card and, if not, will take full responsibility for the payment and any charges accruing to it. By checking the Enroll button below, I agree to pay via my credit card or applicable account the amount shown above and have read and agree to all terms, conditions, and other statements in this enrollment. I understand and agree the enrollment must be fully and accurately completed, signed and dated to be considered, and must be signed by the insured, a legal representative, or proxy. A legal representative or proxy that signs this enrollment represents and warrants his/her authority and capacity to act on behalf of, sign for, and bind each traveler listed.

MERCHANT LOCATION. International Medical Group’s corporate headquarters is located at 9200 Keystone Crossing, Suite 800, Indianapolis, IN USA.

CLAIM FRAUD STATEMENT - FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

ALASKA and KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false, incomplete or misleading information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may be prosecuted under state law.

CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

FLORIDA: WARNING :Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NEW YORK: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

PENNSYLVANIA: 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.

OKLAHOMA: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

TENNESSEE and VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

TEXAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

The coverage provided by this insurance is for travel benefits only. Review your Description of Coverage carefully. Note benefits are subject to all provisions, terms, conditions, limitations and exclusions of the insurance contract including but not limited to a pre-existing condition exclusion. Upon acceptance of the enrollment and payment of the plan cost in full, travel insurance documentation will provide specific information about the plan purchased. The program manager of the coverage is iTravelInsured, Inc. The insurance is underwritten by United States Fire Insurance Company or SiriusPoint America Insurance Company. You are not eligible to purchase coverage if any of the following are true: 1) you are unable to travel; 2) you are limited from travel; 3) you are medically restricted from travel; or 4) you are experiencing and/or are under treatment for any illness or injury that limits or restricts your ability to travel on the date of purchase. (New Hampshire residents the medically fit to travel exclusion only applies to the property and casualty benefits).

Within 10 days of the date of the travel plan documentation, an insured may cancel the coverage by sending a written cancellation request to iTravelInsured and iTravelInsured will then process a plan cost refund so long as the insured has not already departed on the covered trip or filed a claim. No plan cost refunds are payable after 10 days of receiving the travel insurance documentation. If you do not receive the travel insurance documentation or have any further questions, please visit our website at www.itravelinsured.com or contact a representative via email at service@iTravelInsured.com or phone at 1 (317) 655-9796 or (866) 347-6673.