I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Certain Underwriters at Lloyd ’s, London. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Lloyd ’s operates as an approved, 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. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or Paypal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or Paypal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Certain Underwriters at Lloyd ’s, London. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Lloyd ’s operates as an approved, 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. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or Paypal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or Paypal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.

I hereby apply for membership in the Triptime Trust and for insurance provided to members by Underwriters under Master Policy Number PCU02012021. I understand the Plan Administrator is not the insurer. I understand that this insurance is not a general health insurance plan, and it is intended for use in the event of a sudden and unforeseen event while traveling outside my Home Country. I understand this insurance contains a Pre-existing Condition Exclusion, a Pre-certification provision, and other Exclusions which may affect my ability to collect any claim hereunder. I affirm that a copy of the Master Policy has been made available to me (Click Here ), that I have reviewed the Master Policy and I am satisfied that the coverage provided is appropriate for me.

I understand that neither Underwriters nor the Plan Administrator will provide any benefit or service when the provision of such benefit or service would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States. I affirm that I am not listed or referred to on any list published by Office of Foreign Assets Control (OFAC) as a “Specially Designated National ”or “SDN ”. I understand that Underwriters rely on the affirmations contained herein and the information included in the Application in determining whether or not coverage can be extended to me, and that any misrepresentation can result in policy rescission or claim forfeiture, in addition to any other legal remedies available to Underwriters and Plan Administrator.

I understand it is the responsibility of Indian residents purchasing insurance cover to obtain permission from the Central Government and Reserve Bank of India.

I understand that Underwriters under Master Policy PCU02012021 are non-admitted insurers in the United States. As such, claims under this insurance may not be made against any state guaranty fund. I understand and agree that the insurance agent/broker, if any, assisting with this Application is a representative of the Applicant. Licensed insurance brokers and independent agents are compensated through commissions calculated as a percentage of premium for the purchase, renewal, placement or servicing of insurance coverage. If signed by a representative of the Applicant, the undersigned warrants his/her capacity to so act. If signed as guardian or proxy of the Applicant, the undersigned warrants his/her capacity to so act. By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. Rates include surplus lines taxes and fees where applicable.

I understand that coverage is subject to validation and acceptance of payment by my credit card company or PayPal.

By agreeing to continue you are confirming that the information you have submitted is accurate and that the above statements are true. Any incorrect, inaccurate or incomplete information could invalidate all or part of the policy and result in a claim of being rejected or not being paid in full.