EXTENDED PLAN APPLICATION

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 +1 (617) 459-4200.
INSTRUCTIONS
1. Indicate your desired membership and requested start date in the Extended Travel Services Membership Plans and Pricing section. Please choose only one.

2. Complete the Personal Information section in full and indicate you agree to the Member Services Agreement and Terms of Service.

3. Answer all six questions in the Medical History and Information section completely and in detail to the best of your ability.

a. Include dates of diagnosis and treatment. This includes any selections made from question 2.

b. If a question does not apply to you write “N/A” on the line.

c. Please attach additional pages to this application if the lines provided do not give enough space for all information.

d. Medications list must include the reason for taking.

4. Complete the General Information section completely.

5. Sign the last page of the application.

6. Submit your application by

a. Submit this Jotform Application by hitting the Submit button

b. Email: memberservices@globalrescue.com

c. Fax: 617-507-1050

d. Mail to: 85 Mechanic Street, Suite A1-1 Lebanon, NH 03766

__________________________________________________________________

GLOBAL RESCUE | (800) 381-9754 | INTL. +1 (617) 459-4200 | WWW.GLOBALRESCUE.COM
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.
EXTENDED TRAVEL SERVICES MEMBERSHIP PLANS AND PRICING (Please choose only one)
INDIVIDUAL ANNUAL MEMBERSHIPS
Standard (up to 45 consecutive days abroad)
1/4 Year (up to 90 consecutive days abroad)
1/2 Year (up to 180 consecutive days abroad)
SHORT TERM MEMBERSHIPS
7 Day Membership
14 Day Membership
30 Day Membership
TOTALCARE MEMBERSHIPS

Travel Services + Telehealth Consults (Note: Security Add-On only available at Platinum and Unlimited Levels)
Type of Total Care Membership
* Shipping and processing charges may apply for the shipment of your Checkme ProTM.
REQUESTED START DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PERSONAL INFORMATION
Name
Address
City
State:
Zip
Country
Phone Number

Country CodeArea CodePhone Number
Email
example@example.com
Use this email to log onto https://ss.globalrescue.com/#/home?source=grcom to provide further information and research Destination Reports prior to travel
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
I have read the Member Service Agreement
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The Membership Services Agreement can be found here.

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.
How did you hear about us?
RP Code
GLOBAL RESCUE | (800) 381-9754 | INTL. +1 (617) 459-4200 | WWW.GLOBALRESCUE.COM
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:
Cancer Type
Cancer Diagnosis Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cancer Status
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 - state "none" if none.
Please list any hospitalizations, surgeries or procedures you have undergone in the last 5 years with dates- state "none" if none.
Please list any medications you currently take and indicate what you take them for - state "none" if none.
GENERAL INFORMATION
Trip dates and location
Expected activity during travel
Primary Care Provider (PCP)
PCP Address
PCP Phone Number

Country CodeArea CodePhone Number
Do you have a disability?
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,
Name of primary care provider
, and I further authorize my provider and her/his staff to share my medical history and current health information with Global Rescue, LLC.

As of today’s date I am confirming that all of this is up to date information.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
GLOBAL RESCUE | (800) 381-9754 | INTL. +1 (617) 459-4200 | WWW.GLOBALRESCUE.COM
Should be Empty:

EXTENDED PLAN APPLICATION

INSTRUCTIONS

IMPORTANT NOTE

INDIVIDUAL ANNUAL MEMBERSHIPS

SHORT TERM MEMBERSHIPS

TOTALCARE MEMBERSHIPS

PERSONAL INFORMATION

MEDICAL HISTORY AND INFORMATION

GENERAL INFORMATION