Anticipated travel pattern for the next 12 months. If applying for the War & Terrorism or Nuclear, Chemical, Biological perils extension, please provide details of security arrangements in place.
I understand by signing this Application, that I,
residing in the United States. I understand that I must
notify Global Benefits Group / TieCare International immediately of any change in my
and/or my dependents’ residency. Failure to do so may result in the denial of claims as
well as recovery of any claims already paid.
I will submit any address change directly to your main office located at: 26000 Towne
Centre Drive, Suite 100, Foothill
Ranch, CA 92610 USA. Phone: (949) 470-2100; Fax: (949) 457-3116; Email: email@example.com ;
or to your European office located at: Bulevar Zorana Djindjica 81/VI/17, 11000
Belgrade, Serbia. Fax: +381 11 311
9888; Email: firstname.lastname@example.org
I, the Undersigned Hereby:
ANY CHANGES THAT OCCUR TO YOUR MEDICAL HISTORY PRIOR TO ISSUE OF THE POLICY MUST
IMMEDIATELY BE REPORTED TO THE INSURER.