West Coast Global InsuranceServices

www.InsureMeWC.com

West Coast Global Insurance Global Health Insurance Online Questionnaire | Mexico Travel Medical Insurance Questionnaire.

West Coast Global Insurance Services

Ca.Lic. #0E50745

USA - (818) 788-5353

Mex - 01 (800) 099 0614

REQUEST QUOTE - Global Health Insurance Online Questionnaire | Mexico Travel Medical Insurance Questionnaire.

Requested Effective Date :


 
 

INSURED DETAILS

BENEFICIAL OWNERS DETAILS

CONTACT DETAILS

I have Whats App? : Yes No

LOCATION DETAILS


REVIEW & CHECK THE TYPE OF INSURANCE COVERAGE THAT FITS YOUR INDIVIDUAL NEEDS*

Single Trip Global Medical Insurance (Accident & Illness Travel Medical Protection) ? :

 

Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)
A Single Trip protection plan can be defined by an individual or family that is traveling out of their home country from 5 days to 365 days with the plan of returning to the country they hold their citizenship.

 

Multi Trip Global Medical Insurance (Accident & Illness Travel Medical Protection) :

 

Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)
A Multi Trip protection plan can be defined by an individual or family that takes multiple trips in one year out of their home country. No one trip out of their home country is longer than 90 days at one time.

 

Global Major Medical Insurance (Expatriate-International Living) :

 

Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)
An Expatriate can be defined as an individual or family that is living 6 months or longer out of the country they hold citizenship.

 

Air-Evacuation Protection Only (Emergency)

 

Air-Evacuation can be defined as a plan that provides an individual or family an Air Ambulance in the event of a catastrophic medical emergency. No medical coverage is provided.

 

Primary Applicant

 

Height

Weight


Primary Applicant General Questionnaire

I currently have an Active Major Medical Insurance Plan in my Home Country?

No
Yes

My Age is 65 or older and I am a U.S. Citizen, enrolled in Medicare?

No
Yes

I am a U.S. Citizen or Legal Resident of the United States?

No
Yes

Please provide us with details about what is most important to you or if there is anything extra you feel we should know, please add those comments below. We look forward to working with you. West Coast Global Insurance Services


Would you like to include any additional Family Members?

No Yes

Questionnaire

Requested Coverage Start & End Dates?

  

Requested Coverage Start Date?

What Country or Countries will you be Visiting?

+
 

What Country or Countries will you be Living in?

I am currently located in the Country I am requesting Medical coverage for ?

No Yes

The Maximum amount of Days I will be Travelling Outside my Home Country will be No More then:

I will physically be in this country ?

How Many Days of the year are you spending in this Country?

Please select the Deductible that Fits your Individual Needs ?
In an insurance policy, the deductible is the amount of expenses that must be paid out of pocket before an insurer will pay any expenses.

$250 $500 $1,000 $2,500 $5,000 $10,000 $20,000

Please provide your Monthly Medical Insurance Budget?
This is only a point of reference, so we may present to you the BEST
Global Insurance Carrier options that meet your Individual needs

$    $

I currently have an Air Evacuation plan in place now ?

No Yes

I understand that by choosing Air Evacuation ONLY, there will be Zero protection for Medical Expenses incurred prior to the Emergency Air Evacuation:

Yes

(If you are seeking medical coverage as well, please select a Single or Multi Trip plan option. Please note that both Single & Multi Trip plans do NOT provide Hospital of Choice.)

 

COVERAGE PREFERENCES

Is insurance Coverage Important to you in the United States
Premium is reduced up to 50% if coverage in the United States is NOT required

No Yes

Are you looking for a plan that will cover you for Annual Doctor Visits and Preventative Care ?

No Yes

Are you looking for a Catastrophic Only Plan

No Yes

CARRIER MAXIMUM LIMITS OF COVERAGE

Maximum Coverage Benefit
(Please note that the policy maximum benefit may decrease based on carrier age guidelines)

Per Policy Period Lifetime
$350,000 $1,000,000
$1,500,000 $2,000,000
$2,500,000 $3,000,000
$4,000,000 $5,000,000
$8,000,000 $10,000,000
Unlimited
$500,000 $1,000,000
$3,000,000 $5,000,000
$7,000,000 $8,000,000
$9,000,000

How did you hear about West Coast Global Insurance Services?

How did you hear about West Coast Global Insurance Services?

What was the name of the location you saw our Company information?

What search engine?

What did you search for? What were the Key Words used when searching online?

DIGITAL SIGNATURE

I understand that West Coast Real Estate & Insurance, Inc. DBA West Coast Global Insurance Services does not guarantee any coverages and has offered this informal application/questionnaire as a way to collect general information. I understand the above is a submission of my informal application/questionnaire and does not provide insurance coverage for me or the insured item in which I am requesting information about. I understand that the limits of coverage I requested may change once a formal quote is generated from an insurance company and it is my responsibility to review the coverages and policy conditions. I have read the above application/questionnaire and any attachments and I declare that the information I provided is true, complete and correct to the best of my knowledge & belief. This information is being offered to the company as an inducement to issue an insurance policy for which I am applying for and no coverage is offered at this time.

I understand that West Coast Real Estate & Insurance, Inc. DBA West Coast Global Insurance Services will be communicating with me to further assist with my insurance needs and I give my consent to receive telephone calls, text (SMS & MMS) and email messages. Consent to these terms is not a condition of purchase. Message and data rates may apply.
Checking this box serves as my digital signature.

     Change Question