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Atlas America Premium Insurance Application

Please note that :

Not Available for Addresses from the Following U.S. States/Territories: American Samoa (AS).
Not available to individuals who are physically located in follow U.S. states: Maryland (MD), New York (NY) & Washington (WA).
Not available if Home Country/Country of Residences are: Cuba (CUB), Iran (IRN), North Korea (PRK), Puerto Rico (PRI), Ukraine (UKR), United States (USA) & Virgin Islands (USA) (VIR).
Not available for Citizens of: Cuba (CUB), Puerto Rico (PRI), Ukraine (UKR), United States (USA) & Virgin Islands (USA) (VIR).
Not Available for the following Destination Countries: Belarus (BLR), Congo, The Democratic Republic of (COD), Cuba (CUB), Iran (IRN), Israel (ISR), Lebanon (LBN), North Korea (PRK), Palestinian Terr. (PSE), Russia (RUS), South Sudan (SSD), Uganda (UGA) & Ukraine (UKR).
Not available to individuals who are physically located in the country of: Australia (AUS), Austria (AUT), Belgium (BEL), Bulgaria (BGR), Canada (CAN), Croatia (HRV), Cyprus (CYP), Czech Republic (CZE), Denmark (DNK), Estonia (EST), Finland (FIN), France (FRA), Germany (DEU), Greece (GRC), Hungary (HUN), Iceland (ISL), Ireland (IRL), Italy (ITA), Latvia (LVA), Liechtenstein (LIE), Lithuania (LTU), Luxembourg (LUX), Malta (MLT), Netherlands (NLD), Norway (NOR), Poland (POL), Portugal (PRT), Romania (ROU), Slovak Republic (SVK), Slovenia (SVN), Spain (ESP), Sweden (SWE) & United Kingdom (GBR).

All fields are required fields unless stated as optional

Citizenship

Residence / Home Country

Where are you traveling to?

Where are you traveling to? : 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.

Confirm your eligibility

I am not currently located in any .

Are you a US green card holder ?

US green card holder is not eligible for this plan. Here is the list of eligible plans for US green card holder.

Will your trip include the US or US territories?

Sorry, we don't have an online application for your country at this time. Please contact [email protected] for more infomation.

You are not eligible to purchase Atlas Premium because your trip does not include US or US territories. You may be eligible to purchase Atlas Premium International.

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

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

Residents & Citizens of UK may purchase coverage for a maximum of 119 days.

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.
More than one traveler? Enter the oldest person as the Primary Applicant.

Primary Applicant Date of Birth
(Oldest Traveler)

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

Atlas America Premium

Administrative Company

WorldTrips

Carrier / Underwriter

Payment Options

Credit cards accepted:
Debit cards are not accepted.

Comprehensive Coverage Plan

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

Inside USA

After the deductible, within the PPO network, plan pays 100% up to chosen medical maximum. After the deductible, outside the PPO Network, the plan pays up to URC.

Outside the USA

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

Review the policy document for complete policy details including benefits and exclusions and an important notice regarding Affordable Care Act requirements.

Review & Download

Plan Brochure Description of Coverage Insurance Product Information Document