Interexchange Au Pair Usa 13th Month Insurance Extension Form printable pdf download

Interexchange Au Pair Usa 13th Month Insurance Extension Form

InterExchange Au Pair USA-13

Month Insurance Extension Form

Dear Au Pair,

Congratulations on nearing the end of your au pair year! We hope that you have found it to be a

rewarding and enriching experience living in the United States and getting to know the American culture

first hand. Please find enclosed your Return Flight Request Form from Globe Travel Services. Should

you decide to extend your stay in the United States to travel for an additional month, it is

MANDATORY that you purchase supplementary insurance. The cost of this insurance is $50. Below

are instructions for obtaining accident and sickness insurance coverage if you stay for your 30-day travel

period.

Instructions: In order for InterExchange to obtain the one-month additional coverage for you, please

complete the form below. Enclose a money order made out to in the amount of $50. Return both this

form and the money order to:

Au Pair Insurance Extension

161 Sixth Avenue

3rd Floor

New York, NY 10013

(Please PRINT neatly, because if we cannot read your writing, we will not be able to process your

insurance extension.)

First Name ___________________________ Last Name ________________________________

Host Family Name _______________________________

Street Address ____________________________________________________________________

City _____________________________ State __________________ Zip Code ________________

Your date of arrival to the United States ________________________

Your date of departure from the United States ___________________

Signature ____________________________________ Date _______________

________ ______ ______ ______ ______ ___________ ____________ ______ ______ ___ _

________ ______ ______ ______ ______ ___ ______________ ______ ______ __________

For office use only:

Date received: ____________________

Cash Receipt #: ________________________

AP-PA40-0909

Interexchange Au Pair Usa 13th Month Insurance Extension Form