Take Trips. Not Chances.

MedjetAssist is the premier global air-medical

transport membership program in the U.S.

Medjet arranges air-medical transport for

its members who are hospitalized while

traveling 150 miles or more from their

primary residence, in the U.S. or abroad,

to the member’s hospital of choice in their

home country.

Medjet’s services are bedside-to-bedside:

this includes all medical care during

transport. Membership is applicable for

individuals who have a primary residence

in the U.S., Canada or Mexico.

For Rules and Regulati ons visit: www.medjet.com/BocaExpress

A D D I T I O N A L B E N E F I T S

• Ongoing Monitoring of Member’s Medical

Condition

• 24/7 Medical Consultation

• Emergency Message Relay

• Worldwide Medical and Legal Referrals

• Translation Assistance

• Transfer of Mortal Remains

R E T U R N SR E T U R N SR E T U R N SR E T U R N SR E T U R N SR E T U R N SR E T U R N SR E T U R N SR E T U R N SR E T U R N STHE MEDJET ADVANTAGE

Medjet arranges domestic and international transport to the member’s hospital of choice in his/her home country... NOT the nearest appropriate hospital.

•

No adequate facility clause: The Medjet member is given the choice of where they will receive medical care even if the hospital where they are admitted can provide adequate treatment.

•

No adventure travel exclusions; No natural disaster exclusions; No terrorism exclusions.•

No monetary cap; No deductibles; No co-pay; No claim forms; No waiting period.

•

No health questions for members under age 75.•

Yes

Medical Transport Benefits

No Adequate Facility Clause

Member’s choice of receiving hospital

Domestic & International medical transport

Yes

Yes

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* in most cases, location determined by insurer.

MedjetAssist has spent years building a vast global

network of medical evacuation specialists to provide you

C O N N E C T I O N SMEDJET MEMBERSHIP OPT IONS

MEDJET ANNUAL MEMBERSHIP

Travel with the peace of mind our most popular membership provides: protectionfor an unlimited number of domestic trips during the membership year, or up to 90-consecutive days per trip internationally.

MEDJET SHORT-TERM MEMBERSHIP

This program offers the same benefits as the annual membership but is designed for the occasional traveler under age 75.

MEDJET FAMILY MEMBERSHIP

Available in annual and short-term memberships, a family membershipprotects the primary member, their spouse/domestic partner and up to five dependent, unmarried children under age 19 (or up to age 23 if full-time student). Every member of your family is protected, even when you do not travel together.

SPECIALTY MEMBERSHIPS

• Extended Stay Memberships• Collegiate Memberships• Domestic Memberships• Motorcycle Protection• Diamond Membership (ages 75 up to 85)

MedjetAssist is your trusted

travel partner. When you travel 150

miles or more from home you go

with the peace of mind that a team

of travel specialists and medical

experts are your safety net in case

of a medical emergency.

For more information on becoming

a Medjet member, contact

MedjetAssist or your Travel Advisor.

Boca Express Travel561.451.4511

www.Medjet.com/BocaExpress

3500 Colonnade Parkway Suite 500Birmingham, AL 35243 1.800.527.7478

www.medjet.com/BocaExpress

Enrollment Form

ANNUAL MEMBERSHIPS (USD)

INDIvIDUAL FAMILy 1-year $260 $395 2-year $485 $735

3-year $685 $1,035 5-year $1,060 $1,605

Add Medjet Horizon to your Annual Membership for only $139.

** Departure (Effective) Date: ________________

** Return (Expiration) Date: ________________

Add Motorcycle Protection for $35 per year, per motorcycle.

** SHORT-TERM MEMBERSHIPS (USD)

INDIvIDUAL FAMILy 8-Day $99 $185 15-Day $125 $235 21-Day $165 $295 30-Day $195 $365

Membership Total $: ________________

Medjet Membership Options (up to age 75)

Boca Express Travel

Contact your personal travel advisor at:

Boca Express Travel561.451.4511

www.Medjet.com/BocaExpress

Agent Name/Agent Email:

07/2015

Mr. Mrs. Ms. Dr. Rev. (Must be under age 75)

Full Name __________________________________________

Date of Birth _____ /_____ /_____

*Primary Residence _________________________________

_________________________________________________

City ______________________State ____ ZIP _____________

Mailing Address _____________________________________

City ______________________State ____ ZIP _____________

Phone (Day) _______________________________________

Phone (Evening) ___________________________________

Email ___________________________________________

Please list family members’ names and dates of birth

(Dependent Child: Up to 19 or age 23 if a full-time student)

Spouse/Partner: _______________________ DOB: _________

Child 1: ______________________________ DOB: _________

Child 2: ______________________________ DOB: _________

Child 3: ______________________________ DOB: _________

Child 4: ______________________________ DOB: _________

Child 5: ______________________________ DOB: _________

* Primary residence listed above determines mileage eligibility for membership benefits. Members must be hospitalized 150 miles or more from this address.

• Membership must be activated prior to initial departure from primary residence.

• Diamond Memberships are available to travelers ages 75-84.

• Expatriate Memberships are available to those traveling outside their home country for more than 90 consecutive days.

Card Number ____________________________________________

Expiration Date _____/_____/_____

Security Code _________________

Payment Information

Name exactly as it appears on card (please print)

I acknowledge my membership is subject to the Rules and

Regulations in effect at the time of enrollment or renewal.

Check or Money Order Enclosed

visa American Express

MasterCard Discover

(Payable to MedjetAssist)

Fax completed form to: 800.863.3538 or mail to:MedjetAssist • P.O. Box 43099 • Birmingham, AL 35243

Signature Required