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30/7/2015 https://www.guard.me/print_agreement.php?pin=PVY1rsBfzsvhVcnroTnxKw==
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Consent & Agreement
 
I Demo Test declare that all the information I have provided in this Claim Form is true and complete. I acknowledge
receipt of Travel Healthcare Insurance Solutions / guard.me International Insurance's privacy statement. I authorize any
hospital, physician, other medical provider or insurer to provide by any means my complete medical record to Travel
Healthcare Insurance Solutions Inc. / guard.me International Insurance and its insurers for the purpose of administering
claims. All information is to be held in complete confidentiality and is no to be released to any party apart from those
listed above. Use of my email address will be restricted to insurance inquiries unless I initiate email contact. A photocopy
or facsimile transmission of this Claim Form is as valid as the original. I assign my right to payment to the party indicated
above. 
________________________________ 
Demo Test 
July, 30 ­ 2015 
Travel Healthcare Insurance Solutions Inc.  Tel: (905) 731­8291   Toll Free: 1­888­756­8428   Fax: (905) 731­6948   Toll Free Fax: 1­866­329­8447  
claims@guard.me   www.guard.me
ISO9001: 2008 Registered           Underwritten by: Reliable Life Insurance Company  

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