PUERTO RICO ENROLLMENT APPLICATION

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Primary Member Information:

Note: Preexisting conditions are covered after 90-days

Member's Spouse Information:

Note: Preexisting conditions are covered after 90-days

Dependent's Information:

Note: Preexisting conditions are covered after 90-days

Second Dependent's Information:

Note: Preexisting conditions are covered after 90-days

Home Benefits Address:

Mailing Address (IF DIFFERENT FROM HOME BENEFITS ADDRESS):

Agent Information:

Preferred Payment Method: *

Note: a Global Medevac agent will reach out to you to process your payment

REFERRAL INFORMATION:

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Market By: New Indemnity Solutions Corp
787-792-5730
P.O. BOX 270295
San Juan Puerto Rico 00927-0295