Application for Coverage


All Sections Must be Completed in Full. Fields in red are required.
Click here to read notices regarding application.
As described in the brochure and "Insurance Plan" tab on this site, Lifeboat Medical Insurance Plan is a comprehensive medical insurance program designed exclusively for the international citizen. In order to provide you and your family with the coverage you desire, please follow the directions and answer all questions in complete detail.

Please note that Lifeboat Medical Insurance Plan limits coverage in the 50 United States to six months during any given 12 month policy period. This plan is not intended to cover permanent residents of the United States.

Imortant notice, this application currently only functions using internet explorer as your browser. If you are using Netscape or Safari, please call the main office at (630) 221 - 6000 or e-mail Cecille Brechin with all the information below at cecileb@iwic.com.

Section 1. Applicant Information
Leave boxes blank if they don't apply.
Name
(Last, First, Middle, Maiden)		 Sex DOB
(Mo/Day/Yr)		 Birthplace
(State,Country)		 Height
(Ft/In)		 Weight
(lbs)
Primary
Spouse
Child
Child
Child
Applicant's Residence Address
must be outside the United States
street,city,state,country,postal code
 Mailing Address
street,city,state,country,postal code
Applicant's Phone and E-mail
Home Phone: 
Business Phone: 
Fax: 
E-Mail: (required)
Occupation of Primary Insured: 
Occupation of Spouse: 
Previous Occupation: 
Name of Employer: 
If you are a U.S. Citizen, when
do you plan to depart the United States?
Primary Insured is:  Married    Single
Length of time per year outside the US 
Where are you traveling
How long do you require coverage under Lifeboat?
Are all listed dependents who are age 19,20,21, and 22 full time students?
If yes, please list schools and locations
Section 2. Health History Questions for Applicants
In order for your application to be processed successfully, each question must be answered truthfully. Any answers to "yes" questions must be clarified in Section 3 Health History Details. In addition, answers to "yes" questions require an Attending Physicians Statement (APS) dated within the past 90 days. All questions for all applicants must be answered and sufficient medical data reported in order for SRI to underwrite your application.
Within the past (10) years, have you or any applicant been medically advised, referred, counseled, treated, had surgery or been treated, diagnosed or currently taking prescription medical for: (Please 'check' all that apply and state in detail in Section 3. Health History Details. YES NO
1.) Digestive system diseases or disorders (including, but not limited to: gastritis, ulcers, esophagael regurgitation, hemorrhoids, colon or rectum disorders)?
2.) Cardiovascular and/or circulatory diseases or disorders (including, but not limited to: elevated blood pressure, hypertension, elevated cholesterol, heart attack, angina, chest pains, arteriosclerosis, coronary insufficiency, thrombosis, phlebitis, vascular afflictions, rheumatic fever, heart murmur)? If "Yes" attach Attending Physicians Statement (APS) and current blood pressure reading, dated within the past 90 days describing the cardiovascular and/or circulatory condition.
3.) Respiratory diseases or disorders (including, but not limited to: chronic cough, bronchial asthma, bronchitis, tuberculosis, lung disorders, emphysema, respiratory insufficiency, pleurisy pneumonia)?
4.) Diseases or disorders of the eyes, nose, ears and throat (including, but not limited to: nasal septum deviation, chronic sinusitis, cataracts, glaucoma, allergies or hay fever)?
5.) Sexually transmitted diseases or immune deficiency disorder (AIDS/ARC), tested positive for HIV or any related illness?
6.) Diseases or disorders of the Pancreas, Liver, Gall Bladder or endocrine disorders (including, but not limited to: obesity, pituitary or lymph glands, thyroid or metabolic disorders)?
7.) Diabetes? (If "Yes", complete the following)
a) Diabetic Type: (I) (II)
b) Date Diagnosed:
c) Medications:  
d) Controlled by diet only?: Yes  No
e) Date of last HbA1c Test:  
8>) Diseases or disorders of the mental and nervous system (including, but not limited to: epilepsy, convulsions, paralysis, stroke, seizures, chronic headaches, mental retardation, psychosis, mental or behavioral disorders, Down Syndrome or other chromosome disorders, dizziness, fainting spells, vertigo)?
9.) Addictive diseases or disorders (including, but not limited to: alcoholism, chemical or drug abuse or addiction, or has any applicant used illegal drugs or used prescription medication, other than as prescribed)?
10.) Kidney or urinary tract system diseases or disorders (including, but not limited to: kidney or bladder stones and infections)?
11.) Cell or blood diseases or disorders (including, but not limited to: cancer, tumors, cysts, polyps or other growths of the skin or internal organs, hepatitis, leukemia or Kaposi's sarcoma)?
12.) Muscular or skeletal diseases or disorders and inflammation (including, but not limited to:scoliosis, arthritis, rheumatism, gout, tendonitis, joint or vertebrae disorders, osteoporosis)?
13.) Any congenital defect, physical disorder or deformity, or developmental problems, not listed above? Or have you or any applicant been advised to have any diagnostic test, consulted a therapist or physician, hospitalization, surgery, treatment or medical advise or undergone special medical testing, hospitalization, x-rays, electrocardiograms, radiology or blood work?
14.) For male applicants, diseases or disorders of the reproductive system or prostate?
15.) For female applicants, diseases or disorders of the reproductive system or vaginal bleeding, fibroids, nodules or breast cysts, fallopian tubes, ovaries or uterus?
15-a.) For female applicants, are you currently pregnant of had a complicated pregnancy or delivery?
If currently pregnant: due date?
16.) Have you or any applicant ever been rejected, ridered, or premium increased for any Health, Life or Disability Policy?
17.) Are you or any applicant currently hospitalized, disabled or unable to perform normal activities?
18.) In the last 12 months, have you or any applicant used any form of tobacco?
If "Yes" what form of tobacco?
Quantity:
How Often:
19.) Have you or any applicant recently experienced any signs, indications, symptoms, diagnosis or treatment that would cause you to believe that you currently have new medical conditions?
Section 3. Health History Details for Applicants
List details for all "YES" answers to the Section 2 health history questions (use additional paper if necessary). Incomplete answers may delay processing.
Name of Person
Question #		 Condition/Diagnosis,Treatment Medication Prescribed and Results of Treatment Dates Seen & Duration Physician/Clinic Address & Telephone
Section 4. Program Specifics
Please Check Chosen deductible: $500    $1000    $2500    $5000 
Requested Effective Date:
Effective date must be within 60 days of application date
For the AD&D benefit, the Primary Insured shall be the beneficiary of the certificate. If the benefit is utilized for the Primary Insured, his/her estate shall be the beneficiary. If this is not acceptable, please list the beneficiary:
Enter your payment plan type:
 Monthly    Quarterly    Semi Annual    Yearly
Section 5. Premium / Payment
Charter Yacht Society or VICL Member Number
I would like to become a CYS or VICL Beneficiary Member Now for $25.
You must be a CYS Member: (Full Member  Associate Member  Beneficiary Member )
or VICL Member (Full Member  Associate Member  Beneficiary Member
Section 6. Declaration and Enrollment Request/authorization to Release Medical Information:
  • I hereby apply for the Lifeboat Medical Insurance Plan and for the insurance provided by Certain Underwriters at Lloyds, London to the members of the Charter Yacht Society B.V.I. & VICL under the Master Policy issued as a group to their address in the British Virgin Islands.
  • I represent that all information on this Application and any attachments hereto is complete and true to the best of my knowledge and belief. I understand that Specialty Risk International, Inc. (the "Administrator") will rely on all information on this Application in determining whether or not to issue coverage and that any incorrect or complete information may void and/or rescind this insurance at any time upon discovery.
  • I understand that health benefits may be limited or excluded for conditions for which any insured person has received any medical diagnosis or treatment, or taken any medication, or realized the manifestation of a condition before his or her effective date, according to the pre-existing conditions limitations provisions of the pain.
  • I AUTHORIZE any physician, medical practitioner, hospital, clinic, other medical or medically-related facility, the Medical Information Bureau, Inc. (MIB, Inc.), consumer reporting agency, insurance or reinsuring company, or employer having certain information about me or my dependents to give to the Administrator or its legal representative, any and all such information. The nature of the information authorized to be disclosed includes information about: (1) physical condition(s), (2) health history(ies), (3) avocation(3), (4) age(s), (5) occupation(s), (6) personal characteristics. This authorization includes information about (1)drugs, (2)alcoholism, (3)mental illness, or (4)communicable diseases.
  • I UNDERSTAND the information obtained by use of this Authorization will be used by the Administrator to determine eligibility for benefits. I ALSO AUTHORIZE the Administrator to release any information obtained to reinsuring companies, Medical Information Bureau, Inc., or other persons or organizations performing business or legal services in connection with my application, claim, or as may be otherwise lawfully required, or as I may further authorize.
  • I UNDERSTAND that as a resident of a foreign jurisdiction, I may be subject to foreign laws with respect to the type of form of coverage in which I am enrolling. I also understand and agree that responsibility for complying with those foreign laws rests solely on me.
  • I UNDERSTAND that no coverage is effective until I am notified in writing by the Administrator and advised of the official Effective Date. I also UNDERSTAND that if the Administrator does not accept me for coverage, the sole obligation of the Administrator and the Underwriter is to return the premium. I also UNDERSTAND that if I am a United States citizen, coverage in the United States if limited to 6 months during any one 12 month policy period. I also UNDERSTAND that Lloyds operates as an approved but non-admitted insurer in most US states and that claims may not be made against any state guarantee fund. I UNDERSTAND and AGREE that this program is issued under a group membership program located outside of the United States and that the program does not comply with any US state insurance law. I UNDERSTAND that this program is not, nor does it intend to be, a general US health insurance policy.
  • I ALSO UNDERSTAND any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an enrollment form, or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
    		•
    Please "I agree" to verify your agreement (Required)
    I attest (As a Proposed Insured, Guardian of Proposed Insured, or Insured's Spouse if applicable) to the information presented in this online application and understand that the information contained herein will become a part of the insurance contract.
    We will contact you once your application has been approved.