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Trish Freeman Insurance Services
15206 John West Road, Gonzales, LA USA
Email: trish@insurancelady.com website: www.insurancelady.com
Phone: +1 (225) 622-6554   Fax: +1 (225) 622-3070

International Medical Travel Services and Benefits - Enrollment Application

Thank you for your interest in Soter World Services (Guernsey) Trust (SWS), providing services and benefits designed to meet the needs of the medical traveler / medical tourist to include their traveling companions. Complete the below to get pricing and enrollment instructions for travel accident and medical complication benefits specifically designed for those who are undergoing elective medical or dental procedure(s) outside of their country of residence.
Frequently Asked Questions

Medical Traveler Information
Age limits for benefits and services is age 70 or younger
Travel Dates
Travel companion coverage is available at a reasonable additional cost. Please choose the number of travel companions that require this additional coverage.
Agency / Medical Travel Facilitator

If you have a Case Manager or Facilitator that is assisting in arranging your travel and medical needs, please name the Company in the below space. Otherwise, if you are not using a provider of such services, please type "None" in the below space
Hospital

A qualifying medical facility: means a hospital, clinic or place for medical, surgical or dental treatment duly qualified by the jurisdiction where the facility is located, and/or possessing an international accreditation from an ISQua member organization or other recognized international accreditation body.

International Society for Quality in Health Care (ISQua)

Is the Hospital / Facility Eligible?
Procedure Options

If the applicant is to receive more than a single procedure/treatment please choose "OTHER / MULTIPLE" from the drop down listing. You must then list ALL of the procedures/treatments that are scheduled and are likely to occur.
PLEASE NOTE: FAILURE TO DISCLOSE ALL PROCEDURE/TREATMENT PROTOCOLS MAY RESULT IN A CLAIM BEING INVALID.