(TYA) Premium Payment Credit Card - TRICARE Overseas

Form InstructionsTRICARE Young Adult (TYA)Premium Payment Credit Card & EFT Authorization FormUse this form if you would like to initiate or discontinue a TYA premium payment using your credit/debit cardor and electronic fund transfer from your bank account. Forms will be process within 10 days of receipt.Upon receipt of this form International SOS will process all outstanding charges (if any) due for your TYApremium program balance.Section I. – Beneficiary InformationComplete TYA Beneficiary account information. Please do not leave anything blank. Please provider aphone number where we can reach you if we need your assistance in processing the information youprovided on this form.Section II. – Sponsor InformationComplete TYA Sponsor account information for verification of eligibility to enroll to TYA program. Please donot leave anything blank.Section III. - Choose payment optionComplete section for EFT (Electronic Funds Transfer) for checking or savings account debits, or the CreditCard section for Visa or MasterCard payments.Option #1 – Electronic Fund Transfer (EFT) from your Checking or Savings AccountFor EFT, enclose a blank check mark “VOID.” If you prefer not to attach a voided check, you must provideyour bank account number and routing/transit number (see below). The example provided below is for USbank accounts. If you are using non-US financial institution, please contact your financial institution forassistance in obtaining your required information for this form.Option #2 - Credit card payment by Visa and MasterCardCredit card payments are only offered for Visa or MasterCard. For your added security, we ask that youprovide your credit card CVV code. The CVV is a three- or four-digit value printed on the back of your cardlocated near your signature strip.Section IV. Authorized signature (If you are disenrolling from auto monthly payments,select “Disenroll from auto payments” and sign in Section IV)How to Submit Form:Submit a completed copy of page 1 of this form via one of the options belowMail to: International SOS Assistance, IncAttention: TYA Accounts ReceivablePO Box 11689Philadelphia, PA 19116Fax to: +1 215-354-2340Form date: April 25, 2011 Page 2 of 2