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<td width="384" height="48" colspan="17" rowspan="1" valign="top" align="left" xpos="16" content csheight="32"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>NEW ENGLAND BENEFIT SERVICES</b></font></td>
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<td width="368" height="91" colspan="12" rowspan="1" valign="top" align="left" xpos="96" content csheight="80"><font size="6" face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" color="#33cccc">FORTIS SHORT<br>
TERM MEDICAL </font><font size="4" face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" color="#33cccc"><b>application</b></font></td>
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<td width="416" height="69" colspan="18" rowspan="1" valign="top" align="left" xpos="16" content csheight="69"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4"><b>Below is an explanation of how to apply for Fortis Short Term Medical Insurance and a form to email to us as an application for the plan.</b></font></td>
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<ul>
<li type="disc"><a href="#Payment"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>PAYMENT OPTIONS</b></font></a>
<li type="disc"><a href="#When"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>WHEN DOES YOUR COVERAGE BEGIN</b></font></a>
<li type="disc"><a href="#Apply"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>HOW TO APPLY</b></font></a>
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<td width="416" height="24" colspan="18" rowspan="1" valign="top" align="left" xpos="16" content csheight="21"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>Choose from Two Convenient Payment Options</b></font></td>
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<ul>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">The single payment option is ideal if you know the exact number of days coverage is needed. The minimum number of days you may apply for is 30 (31 days for Pennsylvannia, 60 for Minnesota residents) and the maximum is 185.</font>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">The monthly payment option is ideal if you are unsure how long you need coverage. This “pay as you go” option gives you the flexibility to continue coverage for as long as it’s needed (up to 185 days) or stop payments and discontinue the plan once your temporary need ended. You make an initial premium paynebt of 35 days (65 days for Minnesota residents). Then, shortly after you receive your contract, Fortis Insurance Company will send you a sheet of payment coupons. Each coupon pays for an additional 30 days of coverage.</font>
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<td width="272" height="32" colspan="7" rowspan="1" valign="top" align="left" xpos="80" content csheight="29"><font face="Times New Roman,Georgia,Times" size="4" color="#33cc33"><a name="When"></a></font><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4" color="#33cc33"><b>When does your coverage begin?</b></font></td>
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<td width="416" height="25" colspan="18" rowspan="1" valign="top" align="left" xpos="16" content csheight="21"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>Your effective date of coverage will begin the later of:</b></font></td>
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<ol>
<li type="1"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">12:01 a.m. the day after your requested policy date; or</font>
<li type="1"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">12:01 a.m. the day after the postmark date affixed by the U.S. Post Office*, provided the following conditions are met:</font>
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<td width="416" height="54" colspan="17" rowspan="1" valign="top" align="left" xpos="64" content csheight="49"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Your application and the full premium payment are received by your agent or Fortis Health; Your answers on the application are complete and meet the requirements for acceptance.</font></td>
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<td width="416" height="89" colspan="18" rowspan="1" valign="top" align="left" xpos="32" content csheight="63"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">*If the envelope containing your application is not postmarked by the U.S. Post Office, or if the postmark is not legible, the policy date will be the later of: a) your requested date; or b) two days prior to the date the application is received by mail by your agent or Fortis Health</font></td>
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<td width="128" height="31" colspan="4" rowspan="1" valign="top" align="left" xpos="80" content csheight="29"><font face="Times New Roman,Georgia,Times" size="4" color="#33cc33"><a name="Apply"></a></font><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4" color="#33cc33"><b>How to apply</b></font></td>
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<ol>
<li type="1"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>First, request rates by phone or email</b></font>
<li type="1"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>When you receive your rate information and application, fill out the application (or apply using the form below), and mail or fax it to New England Benefit Services</b></font>
<li type="1"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>Your policy will be mailed to you shortly after the application is processed</b></font>
</ol>
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<td width="144" height="24" colspan="7" rowspan="1" valign="top" align="left" xpos="54" content csheight="24"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4" color="#33cc33"><b>Please note:</b></font></td>
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<td width="368" height="24" colspan="12" rowspan="1" valign="top" align="left" xpos="66" content csheight="21"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular"><b>Coverage is NOT available</b> for residents in the following states:</font></td>
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<ul>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Alaska</font>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Hawaii</font>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Puerto Rico</font>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Massachusetts</font>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">New Jersey</font>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">New York</font>
<li type="disc"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Vermont</font>
</ul>
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<td width="416" height="66" colspan="17" rowspan="1" valign="top" align="left" xpos="62" content csheight="52"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Please call <a href="contactus.html">Sharon at New England Benefit Services</a> for a personal insurance consultation if you are a resident of a state where Fortis Short Term Medical is not available.</font></td>
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<td width="16" height="16" colspan="2" rowspan="1" valign="top" align="left" xpos="64"><a name="Thank You"></a></td>
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<h3><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Thank You</font></h3>
<h3><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Your Form Has Been Submitted.</font></h3>
<h3><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular">Someone will contact you within 24 hours.</font></h3>
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<center>
<a href="homebody.html"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4"><b>Home</b></font></a><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4"><b> / <a href="fss.html">Fortis Student Select</a> /</b></font><a href="img.html"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4"><b> IMG International</b></font></a>
<p><a href="aboutus.html"><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4"><b>About Us</b></font></a><font face="Arial,Helvetica,Geneva,Swiss,SunSans-Regular" size="4"><b> / <a href="contactus.html">Contact Us</a> / <a href="links.html">Links</a></b></font></center>
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<a name="Anchor-49575"></a></font></h1>
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