Travel Health Insurance - International Health Insurance for Leisure, Business, and Student Travelers

Product Type:

Destination:

Primary Destination:
Location comprising the
most travel days.

Start Effective Date

Date subject to underwriting and approval

MONTH:

DAY:

YEAR:

Effective Date:

Select a date in the next 6 months

Departure Date:

(mm/dd/yyyy)

Return Date:

(mm/dd/yyyy)

Length of Coverage

Traveler and Family Dates of Birth: (Travelers must be age or younger; Eligible Family only.)	MONTH	DAY	YEAR
Traveler 1 (Subscriber)
Traveler 2
Traveler 3
Traveler 4
Traveler 5
Traveler 6
Traveler 7
Traveler 8
Traveler 9
Traveler 10

Age of Traveler(s)

(Enter ages as of today. One traveler per box, the main subscriber first. All travelers must reside in the same U.S. state. For children under 1, enter 0.)

Are you a U.S. Citizen

Yes No

Optional Prescription Drug Coverage

Yes No

Include U.S. Coverage

Yes No

Keeping U.S. Primary Health Plan

Yes No

Are you eligible for Medicare

Yes No

Do you have Primary Health Insurance

Yes No

First Name

Last Name

Email

Phone Number

State of Residence:

5 digit U.S. Zip Code

Citizenship

Trip Cost ($USD):

Per Person Total

Covered Individuals

Enter age as of requested effective date of the policy, one individual per box.
For children under 1, enter 0.
For children older than age 17, please indicate a gender.

Covered Individuals	Date of Birth			Gender
Covered Individuals	MONTH	DAY	YEAR	Gender
	Age	Gender
Participant:
Spouse:
Child 1:
Child 2:					X
Child 3:					X
Child 4:					X
Child 5:					X
Child 6:					X
Child 7:					X
Child 8:					X
Add a Child
I'd rather enter ages I'd rather enter dates of birth

Travelers:

Age Band

Number of Travelers

0 - 18

19 - 29

30 - 39

40 - 49

50 - 59

60 - 64

65 - 69

70 - 74

75 - 84

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