| A. INSTRUCTIONS |
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| 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 WEA Ltd. |
| 4. |
Enter the name(s) of those family members currently eligible for coverage. |
8. |
This plan covers US citizens living abroad. Your Requested Effective Date must be your date of your departure from the United States. 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. |
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| B. PERSONAL INFORMATION |
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Applicant's First Name
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Middle Initial
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Last Name
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Nationality
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Passport or Federal ID
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Date of Birth(MM/DD/YYYY)
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Male
Female |
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Country of Residence
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Occupation
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Claims Mailing Address:This address will be where all claims reimbursements and explanations of benefits will be mailed. |
Street and Number
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City
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State/Province
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Country
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Postal Code
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Home Phone Number
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E-mail Address
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| C. INSURED INFORMATION |
Full Name of Individuals
to be Insured
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Relationship
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Nationality
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Government ID
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Sex
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Date of Birth
(MM/DD/YYYY)
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Full Time
Student
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Height
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Weight
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