Global Medical Insurance Enrollment Info
A. INSTRUCTIONS    
1. Read all agreement terms carefully and complete all sections. Please submit any additional information or required paperwork to app-info@weadirect.com. 5. All family members must apply for the same deductible.
2. Review your answers to each question on this Application for accuracy. Unanswered questions or incomplete information will delay processing. 6. You may submit payment online after completing the application.
3. If you are signing for the applicant, please provide power of attorney documents with the application. 7. All payments should be made payable to Lyncpay.
4. Enter the name(s) of those family members currently eligible for coverage. 8. This plan covers US citizens living abroad as well as other expatriates living outside their country of residence. Your Requested Effective Date must be the date of your departure from the United States or your country of residence. Your Requested Effective Date must also be within 30 days of submitting your application. This plan is not available for Persons living permanently in the United States.
       
 
B. PERSONAL INFORMATION    
Applicant's First Name
Middle Initial
Last Name
Nationality
Passport or Federal ID
Date of Birth(MM/DD/YYYY)
Male  Female  
Host Country
Occupation
   

Claims Mailing Address:
This address will be where all claims reimbursements and explanations of benefits will be mailed.
Street and Number
City
State/Province
Country
Postal Code
Home Phone Number
E-mail Address
 
       
 
C. INSURED INFORMATION
Full Name of Individuals
to be Insured
Relationship
Nationality
Government ID
Sex
Date of Birth
(MM/DD/YYYY)
Full Time
Student
Height

Weight