Application- Liaison Traveler

OFFICIAL UUSE ONLY:    Cert#:                     Processed:                    Eff Date:              Agent: Global Underwriters - 1010 - shpkiwi 

Applicant Information

¨ Mr.     ¨ Mrs.    ¨ Miss    ¨ Ms 

Last Name: _______________________________________

First Name: _______________________________ MI _____

Date of Birth: ___ / ___ / ___ (month/day/year)

Passport Number: _________________________________

Issuing Country: ___________________________________

What do you consider your Home Country?

___________________________________

What is your Nationality?

___________________________________

Address of Correspondence

Address: _________________________________________

________________________________________________

City/State: ________________________________________

Postal Zip Code: _____________ Country: ______________

Work phone (   ) __________ Home phone (   ) __________

Email Address ____________________________________

For AD&D benefit...

Beneficiary _______________________________________

Relationship ______________________________________

For Couple or Family Coverage...                     mm/ dd / yy

Names of additional persons to be insured?        Date of Birth

Spouse _____________________________    ___ / ___ / ___

Child    _____________________________    ___ / ___ / ___

Child    _____________________________    ___ / ___ / ___

Child    _____________________________    ___ / ___ / ___

Child    _____________________________    ___ / ___ / ___

(please attach separate sheet for additional children)

Have you purchased insurance through SRI before?    

¨ Yes  ¨ No

If yes, when?  From _____________ to ______________

Requested Effective Date of coverage:

Month: _____  Day:  _____   Year: _____

*Note: Coverage cannot begin until SRI receives your application and correct premium.

Calculating Your Premium

Select Policy Period: ¨ 3-Months  ¨ 6-Months  ¨ 12-Months

Select Plan Type:  ¨ Single (applicant only)  ¨ Couple   ¨ Family

                      (Be sure to use correct premium)

                                                                                    Premium

Standard Program                                             US$ _____________

        Standard Upgrade Options (if applicable)

        Increase AD&D to:   US$ _________          US$ _____________

(The U.S. must be your Home Country)

                          Plus Admin Fee:                        US$ ____10.00___

                          Total Payment Enclosed:          US$ _____________

Method of Payment

¨ Check  ¨ Money Order   ¨ MasterCard   ¨ Visa   ¨ Discover

Card# _________________________________________________

Expiration Date: _____________ Daytime phone: _______________

Name as it appears on card ________________________________

Signature (required) _____________________________________

Billing Address: __________________________________________

_______________________________________________________

Only one Liaison Traveler program may be purchased for any given policy period.   Make Check or Money Order payable to: "SRI".  Total Payment for the Full Term of coverage requested must be paid in U.S. dollars at the time application for coverage is made.  Coverage purchased by credit card is subject to validation and acceptance by credit card company.  I declare that I understand the terms and conditions of this product, as outlined in this brochure.   I hereby subscribe to the AIG Life Trust and enroll in the group coverage for which I am eligible under the group contract issued by The Insurance Company of the State of Pennsylvania, a member of American International Group, Inc. (AIG).

__________________________________________________  Signature of Insured or Proxy                                   Date  (required)