Questions for Individual Health Insurance
In what area of the world do you need cover	Worldwide including US and Canada Worldwide excluding US and Canada
What type of cover do you need	Hospitalization Only Hospitalization, Specialist Care and Out-Patient
Do you need cover for Maternity?	yes no
Do you need cover for pre-existing conditions?	yes no
Do you need foreign claims reimbursement?	yes no
Do you need 24 hour emergency assistance?	yes no
Do you need Emergency Medical Evacuation?	yes no
Would you like to have direct payment to hospitals in the US?	yes no
Would you like to have direct payment to hospitals worldwide?	yes no
Would you like to have wellness benefits included?	yes no
What deductible would you like?	$ 250 $ 500 $ 1,000 $ 5,000
For whom do you need coverage?	Myself only Myself and spouse Myself, spouse and children Myself and children
My birthday:	Birthday of spouse: Ages of children
What is your nationality?
Country of residence during period of cover?
When would you like coverage to begin?

Name		Postal Code
Address		City
Telephone		Country
Fax		E-Mail
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