52.45.148.122
<?xml version="1.0" encoding="UTF-8"?>
<RegistrationXML>
  <ReferenceId>6198b1b4</ReferenceId>
  <PlanId>2</PlanId>
  <DeductibleAmount>250</DeductibleAmount>
  <MaximumLimit>60000</MaximumLimit>
  <StartDate>07/17/2019</StartDate>
  <EndDate>08/16/2019</EndDate>
  <DestinationPlan>United States</DestinationPlan>
  <NoOfApplicants>1</NoOfApplicants>
  <PersonalInfo>
    <Applicants>
  <Applicant>
    <Firstname>dennis</Firstname>
    <Middlename>j</Middlename>
    <Lastname>broe</Lastname>
    <Age>66</Age>
    <Dob>01/31/1953</Dob>
    <Gender>Male</Gender>
    <SportsRider>no</SportsRider>
  </Applicant>
</Applicants>
  </PersonalInfo>
  <DepartureInfo>
    <HomeCountryDepartureDate>07/17/2019</HomeCountryDepartureDate>
  </DepartureInfo>
  <ApplicantAddress>
    <ResidenceAddress>
      <Address1>32 rue des fosses saint bernard</Address1>
      <Address2/>
      <Country>France</Country>
      <State/>
      <City>Paris</City>
      <Postcode>75005</Postcode>
    </ResidenceAddress>
    <CitizenshipCountry/>
    <Email>dennis.broe@liu.edu</Email>
    <Phone>
      <Home>33769422684</Home>
    </Phone>
  </ApplicantAddress>
  <Beneficiary>
    <AdDBeneficiaryName>lamsri lamsri</AdDBeneficiaryName>
    <AdDBeneficiaryRelationship>Spouse</AdDBeneficiaryRelationship>
    <UniqueIdentifierType/>
    <UniqueIdentifierNumber/>
    <IssuingCountry/>
  </Beneficiary>
  <CourierCharges>No</CourierCharges>
  <PaymentMethod>
    <Creditcard>
      <CreditcardType>Visa</CreditcardType>
      <CreditcardNumber>4809901018042469</CreditcardNumber>
      <NameonCreditcard>dennis broe</NameonCreditcard>
      <CreditcardExpirationMonth>7</CreditcardExpirationMonth>
      <CreditcardExpirationYear>2022</CreditcardExpirationYear>
      <CreditcardAmount>161.2</CreditcardAmount>
      <CreditcardCodeNumber>691</CreditcardCodeNumber>
    </Creditcard>
  </PaymentMethod>
</RegistrationXML>