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