Patriot Group Exchange ProgramSM

Please complete the following form in order to begin your Patriot Group Exchange ProgramSM application.

If you would like to save your application and complete it at a later time, simply click on the "Save Application" button at the bottom of any page of the application after selecting a premium amount and before submitting your credit card information. If you have the Authorization Number and Password from a previous application that was not completed, click here to continue with the previous application.

* Denotes a required field.

U.S.
Non-U.S.  
(Premium only available in monthly increments)
 
 
Age
# of Primary Insureds # of Spouses # of Dependent Children
 
 
 
 
--- Select a Country ---select
Optional File Upload

You have the option to upload a comma-separated value (CSV) file containing the group insureds. Select your file by clicking on the "Browse" button. Then, click on the "Upload" button.

   

For Work and Travel programs please contact your producer or IMG for rates.

Other IMG plans that may be of interest

For a complete list of international medical insurance plans, please click here.

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