Please Print your Name (as you would like it to appear on your ID card):

(Last)		(First)		(Middle)
Passport #:
Send Certificate of Insurance to:
Name:
Address:
Telephone:			Fax:
Requested Effective Date:			Date of Departure:
Date of Return to Home Country:			Country of Citizenship:
Countries to be visited:
Name of Beneficiary: (Note: You will be the Beneficiary for spouse and dependent children included on this Application.)

HOW DO I CALCULATE MY PREMIUM?

Follow these instructions (Review an example: completed application) :

1. Select One Plan and One Payment Option: (Review or print Coverage and Plans, Rates and Payment Options, or Apply Online)

ATLAS INTERNATIONAL	__ Option #1	__ Option #2	__ Option #3	__ Option #4
ATLAS AMERICA	__ Option #5	__ Option #6	__ Option #7
ATLAS EXTRA	__ Option #8	__ Option #9	__ Option #10	__ Option #11

2. List the names of individuals to be covered, and the appropriate premium for the Plan and Option selected:

	Name:	Date of Birth	Monthly Premium	15 day Premium
Applicant:
Spouse:			+	+
Child:			+	+
Child:			+	+
Subtotal:	-	-	A. $	B. $

3. Complete the following:

A.$ __________ (from above)	X	__________ (number of months)	=	C.$ __________
C.$ __________	+	B.$ __________ (from above)	=	D.$ __________
D.$ __________	X	__________ (Deductible Factor - see below)	=	F.$ __________
F.$ __________ (Optional Hazardous Sports Rider)	X	1.08	=	G.$ __________
G.$ __________	+	$ 15.00 (optional overnight charge)	=	H.$ __________    TOTAL PAYMENT

All Products: Deductible  - Deductible Factor, (Choose the deductible and input the associated factor in the table above.) $100 - 1.10 $250 - 1.00 $500 - .95 $1000 - .85 $2500 - .75

4. If you are purchasing the Hazardous Sports Rider, please describe the activities for which you are seeking coverage:

5. Complete the following:

Payment Mode:	__ Check/Money Order *	__ Master Card
	__ Visa Card	__ American Express
Credit Card #:		Expiration Date:
Name as it appears on card:
Signature:		Daytime Phone #:
Billing Address:
* Check or Money Orders should be made payable, in US dollars, to MultiNational Underwriters, Inc. If paying by credit card, I authorize MultiNational Underwriters, Inc. to debit my VISA, MasterCard or American Express account for the amount specified in H. above. Coverage purchased by credit card is subject to validation and acceptance by the credit card company.

6. Read and sign below.

I hereby apply for membership in the Atlas/International Citizen Group Insurance Trust, for the insurance provided to members by Lloyd's. I understand that this is not a general health insurance policy and that it is intended for use in the event of a sudden and unexpected event while I am traveling outside of my Home Country. I understand that Pre-existing Conditions are not covered. I understand this insurance contains a Pre-certification Penalty, and other restrictions and exclusions. I understand this insurance is not renewable and successive periods of insurance will require re-satisfaction of the Deductible and Coinsurance. I understand that the information contained herein is a summary of the Master Policy, and that I may obtain a complete copy of the Master Policy upon request. I understand that Lloyd's operates as an approved but non-admitted insurer in all states of the United States except Illinois and Kentucky where they are admitted. As such, claims under this insurance may not be made against any state guaranty fund. If signed by an agent of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage, the Applicant ratifies the authority of the signatory to bind him/her. The undersigned authorizes any doctor, medical practitioner, hospital, clinic, health facility, pharmacy, government agency, insurance agency, insurance company, group policyholder or insurance or benefit administrator or any other entity having information as to the care, advice, treatment, diagnosis or physical or mental condition of any person listed on this Application to release said information to MultiNational Underwriters, Inc.

Signature of Applicant (or Guardian):_______________________ Date:__________ Signature of Spouse:_______________________ Date:__________

7. For Agent Use Only:

Producer Number: 99646	Producer Name: AuPairInsurance
Company Name: AuPairInsurance	Street Address: 15 Cottage Avenue, Suite 201
City: Quincy	State: MA	Postal Code: 02169
Country: USA	Telephone: 617-328-1565	Fax: 617-328-0615
E-mail Address: webmaster@AuPairInsurance.com

Make checks payable to: Multi-National Underwriters and send completed application to:

MNUI   c/o AuPairInsurance 15 Cottage Avenue, Suite 201 Quincy, MA 02169   USA Free Phone: 877-328-1565 Phone 617-328-1565 / Fax: 617-328-0615 www.AuPairInsurance.com

Copyright ©  Multinational Underwriters, Inc. All rights reserved.