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I understand that this 12 month policy provides coverage for multiple trips of 30 or 45 days duration or less.

Are you a US citizen and/or a US resident?

Yes No

Will your trip include the US or US territories as a destination country?

Yes No

Do you maintain medical insurance coverage in your Home Country?

Yes No

Date Coverage Should Begin:

mm/dd/yyyy

Applicant Date of Birth:

mm/dd/yyyy

Spouse Date of Birth (if to be covered):

mm/dd/yyyy

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