Marion Medical Mission Trip 2008
Group Travel Medical Insurance
For those volunteers who plan to travel to Africa with the Marion
Medical Mission Team 2008:
If you are interested in group travel
medical insurance for the trip, please fill out the form below and return it with a check
for the amount to cover the number of days you plan to be traveling. Please make the check
payable to International Medical Group (IMG) Insurance. We need to receive your
information form and check before August 1, 2008 to ensure time to get your insurance
information to you before you leave.
Marion Medical Mission
1412 Shawnee Drive
Marion,
IL 62959
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Information for Patriot Group Travel Medical Insurance:
Name as it appears in your
passport:________________________________________________
Date of birth:_____________________________ Passport Number:_____________________
Request Effectiveness
Date:_________________ Request
Expiration Date:_______________
Number of days of coverage
required:_________ *Daily
Rate:_________________________
