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APPLICANT DETAILS
PAYMENT

Patriot Platinum Insurance Application

Please note that :

Not Available for Addresses from the Following U.S. States/Territories: Maryland (MD) & New York (NY).
Not available if Home Country/Country of Residences are: Botswana (BWA), Cuba (CUB), Gambia (GMB), Ghana (GHA), Iran (IRN), Kosovo (XKX), Niger (NER), Nigeria (NGA), North Korea (PRK), Sierra Leone (SLE), Syria (SYR), U.S Virgin Islands (VIR), United States (USA) & Venezuela (VEN).
Not available for Citizens of: Botswana (BWA), Gambia (GMB), Ghana (GHA), Kosovo (XKX), Niger (NER), Nigeria (NGA) & Sierra Leone (SLE).

All fields are required fields unless stated as optional

Citizenship

Residence / Home Country

Where are you traveling to?

Sorry, we don't have an online application for your country at this time. Please contact support@visitorscoverage.com for more infomation.

Traveling to Multiple Countries? : If any part of your trip includes the United States, please select United States as your Destination Country. Other countries except Home Country on your trip is automatically covered.

Date of arrival

Coverage Start Date
(Begins at 12:00 AM EST)

Coverage End Date
(Ends at 11:59 PM EST)

Coverage Area

Please use the date of birth that appears in your travel documents, for e.g passport. A request to correct date of birth after the policy is purchased may result in changes to policy premium and benefits.

Applicant Date of Birth

Spouse Coverage Needed

Spouse Date of Birth

Child Coverage Needed
(17 years and under)

Dependent Child: Children 17 years and under of the primary insured on this policy. Grandchildren, nieces, nephews etc. are not considered as dependent children. Please fill a separate application in such cases or for older children.

+ Add Child

Is the applicant present in the USA ?

You are not eligible to purchase Patriot Platinum due to restriction of plan. You may be eligible to purchase Global Medical Insurance.

You are not eligible to purchase Patriot Platinum due to restriction of plan.

Where can we email your policy details?

Email Address

Will be used for communicating policy related notifications.

Patriot Platinum

Administrative Company

IMG

Carrier / Underwriter

Sirius Specialty Insurance Corporation

Payment Options

Credit cards accepted:
Debit cards with MasterCard or Visa logo are accepted.

Eligibility

For non US residents traveling outside their home country.
Coverage for minimum 5 days to maximum up to 365 days in a policy period.
Renewal option available up to a maximum of 3 years.

Comprehensive Coverage Plan

The comprehensive plan provides percentage of eligible expenses, up to the policy maximum.

Inside US and Canada

In-Network : After the deductible, plan pays 100% up to chosen medical maximum.
Out of Network : : After the deductible, plan pays 90% of first $5,000; then 100% up to chosen medical maximum.

Outside US and Canada

After the deductible, 100% up to the chosen medical maximum.

Review Policy document(Description of Coverage) ,for complete policy details including benefits and exclusions.

Review & Download

Plan Brochure Description of Coverage

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