International Medical Travel Insurance and Services - Enrollment Application

If you need to amend or make corrections to previously submitted information, do not use your browser back / forward buttons. Please use the blue navigation buttons below. You must resubmit each page before proceeding to the next by clicking the submit button at the bottom of each page.

General Information Maximum Sum Payable Address Details, Beneficiaries, Travel Companions

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PATIENT CERTIFICATION

* required - I have read and understand the COVID benefits, requirements, exclusions and confirm they may effect coverage eligibility.

* required - I certify that I am physically fit to travel internationally and have not been advised or believe that travel may cause any additional health risks.

* required - I Understand certain medical procedures are corrective procedures for an existing illness. Included in coverage are benefits for a complications of a medical procedure, however pre-existing conditions are not covered accidents.

* required - I Understand: CUSTOM ASSURANCE PLACEMENTS, LTD. DISCLAIMERS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (Not Applicable in CO, HI, NE, OH, OK, or VT; in DC, LA, ME, TN, VA and outside of the United States, Insurance benefits may also be denied).

Comments: Please note any additional information

PLEASE REVIEW YOUR DETAILS BELOW BEFORE SUBMITTING FOR APPROVAL

Summary of Application Details for:

Application ID №: GPS0
Telephone:
Email:
Date of Birth: 01 Jan 1970
Occupation:

Passport Country of Issue:
Passport №:

Home Address:

,

Departure Date: 01 Jan 1970
Return Date: 01 Jan 1970
Date of Procedure: 01 Jan 1970

Complications coverage for the duration of your trip only.

Procedure:
Rating Class:

Maximum Sum Limit: $0.00
Insurance and Services Cost: $ 0.00
Crisis24 Horizon Mobile app for travel security: $0.00 for 0 total travellers for 0 days.
TOTAL: $0.00

Medical Facility:
,

Beneficiary Information:
Number of Beneficiaries: 0

Covid Coverage: $25,000.00 - Included for enrolled insured and companion(s): No

How you heard about us:

You can check on the status of your enrollment anytime by logging in here.
Please give us 2 business days to review your enrolment. If you have not received and email advising you of the status of your enrollment within 2 business days, please check your spam filter or email us directly.

Submit this request for approval and to receive instructions via email. I understand that additional information may be required before coverage can be confirmed.

If you need to amend or make corrections to previously submitted information, do not use your browser back / forward buttons. This may result in data loss. Please use the blue navigation buttons towards the top of the page. You must resubmit each page before proceeding to the next by clicking the submit button at the bottom of each page.