Extended Plan Application

Since 2004, Global Rescue has been the world’s leading provider of medical, security, evacuation and travel risk management services to enterprises, governments and individuals.

Extended Memberships are for travelers 75 to 85 years of age. For individuals over age 85, medical transport benefits are available on a fee-for-service basis. Please complete this application if you are or will be 75 years of age or older when traveling. If insufficient space, attach additional pages to the form when submitting, i.e. problem list, medication list, etc. After payment is received, your membership becomes effective on the date indicated during sign up. You will receive an email when your account has been activated. Applications cannot be submitted more than 90 days prior to the membership start date.

For more information regarding Global Rescue membership services, visit www.globalrescue.com, or call (617) 459-4200.

INSTRUCTIONS :

Indicate your desired membership in the Extended Travel Services Membership Plans and Pricing section. Please choose only one.
Complete the General Information and Payment Information sections in full and indicate you agree to the Member Services Agreement and Terms of Service.
Answer all six questions in the Medical History and Information section completely and in detail to the best of your ability, including dates of diagnosis and treatment.
- If a question does not apply to you write “N/A” on the line.
- Please attach additional pages to this application if the lines provided do not give enough space for all information.
- Medications list must include the reason for taking.
Complete the Personal Information section completely.
Sign both pages of the application.
Submit your application.

IMPORTANT NOTE:

If the Member omits relevant medical information, is hospitalized due to circumstances diagnosed or treated within one year prior to this application, or for which symptoms existed which would cause a prudent person to seek such diagnosis or treatment, travel benefits may be excluded or denied. Acceptance of this form does not constitute a guarantee of services.

[cf7mls_step cf7mls_step-1 "Next" ""]EXTENDED TRAVEL SERVICES MEMBERSHIP PLANS AND PRICING (Please choose only one)

INDIVIDUAL ANNUAL MEMBERSHIPS	Medical Only	Medical & Security
Standard (up to 45 consecutive days abroad)	$699	$1,399
1/4 Year (up to 90 consecutive days abroad)	$899	$1,799
1/2 Year (up to 180 consecutive days abroad)	$1,099	$2,199

SHORT TERM MEMBERSHIPS	Medical Only	Medical & Security
7 Day Membership	$259	$509
14 Day Membership	$339	$679
30 Day Membership	$489	$979

TOTALCARESM MEMBERSHIPS	Max Travel Days	Urgent Care Consults	Medical Only	Medical & Security
Silver Membership (domestic only)	n/a	1	$590	n/a
Gold Membership	45	1	$1,340	n/a
Platinum Membership	90	4	n/a	$2,540
Unlimited Membership	Unlimited	Unlimited	n/a	$5,040

PERSONAL INFORMATION

Name

Gender

DOB *

phone

Address

City

State

Country

PAYMENT INFORMATION

Credit Card Number

Exp Date

CVV

(*The three- or four-digit security code on the front or back of the card)

Billing Address

State

Zip

Signature

How did you hear about us?

RP Code

YES I have read and agree to the Member Services Agreement on the Global Rescue website. Date:
The Membership Services Agreement can be found at http://www.globalrescue.com/agreement.cfm
You will receive an email when your account has been activated. Global Rescue encourages you to log into your account and fill in critical information, such as emergency contacts, health history, etc.
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MEDICAL HISTORY AND INFORMATION

Do you have any allergies, including any medications? If so, please list them here

Have you ever been diagnosed and/or treated for any of the following:

High blood pressure	Diabetes	Rheumatoid disorder	Altitude sickness
Asthma	High cholestero	Stomach problems or ulcers	Dementia
Emphysema/ COPD	Angina or chest discomfort	Liver problems including hepatitis	Cancer
Sleep apnea	Heart problems	Liver problems including hepatitis	I travel with my breathing machine
Arrhythmia	Anemia or low blood count	Stroke	Thyroid problems
Kidney problems	Kidney stones	Mental health conditions	Other
None of the below

Please explain any above medical conditions to include diagnosis and treatment dates

Please list any medical conditions not listed above, and include diagnosis and treatment dates

Please list any hospitalizations, surgeries or procedures you have undergone in the last 5 years with dates

Please list any medications you currently take and indicate what you take them for

GENERAL INFORMATION

Trip dates and location

Expected activity during travel

Primary Care Provider

Address

Phone Number

Do you have a disability?
YESNO

If yes, please explain

We may need to contact your primary care provider before approving your application. Do you consent to Global Rescue and physicians at
Elite Medical Group contacting the above-named provider for this purpose? If so, please sign the statement below

I authorize Global Rescue, LLC, to contact my provider and I further authorize my provider and her/
his staff to share my medical history and current health information with Global Rescue, LLC.

Signature

Date

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Company

Phone:
1-877-813-0803
Email:
info@sixkind.com

Social Media

Address

218 N. Lee Street, Ste. 314 Alexandria, VA 22314
Phone:
1-877-813-0 803
Email:
info@sixkind.com