Travel Insurance Questionnaire
Answer a few questions and receive a quote within 24-48 hours!
Travel Agent Name: (If applicable.)
Thank you for submitting your client for a quote!
Primary Traveler’s Full Name & Date of Birth
*
The Primary Traveler is the policy owner and main point of contact. Coverage details will apply equally to all travelers listed on this policy.
Primary Travelers Date of Birth:
Departure Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Return Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of the initial deposit made on the trip:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
(Note: If payment was made more than 14 days prior to purchasing insurance, some coverages may not apply. Such as cancel for any reason, or pre-existing conditions on accident/medical.)
Total Cost of the Trip:
*
Include flights, hotel, rental car, etc.
Destination(s) Clients are Traveling:
*
If more than one location please provide them all.
Supplier: (Example, Delta Vacations, Apple, Classic, etc.)
If you're booking direct with the hotel, or piecing the trip together please note with which airline, hotel, etc. you are working with.
Primary Travelers Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Travelers Phone Number:
*
Primary Travelers Email Address:
*
Additional Household Travelers (Optional)
If other members of your household are traveling with you, you may include them in your policy. All additional travelers must reside at the same home address as the Primary Traveler. Please list each traveler’s Full Name and Date of Birth above.
Additional Household Travelers (Optional)
Additional Household Travelers (Optional)
Additional Household Travelers (Optional)
Annual policies can sometimes be around the same cost as a single vacation/trip. However to purchase an annual policy you must have a "trip" coming up within 60 days. The "first trip" does not have to be out of the USA, it can be domestic. If you would like an annual policy quoted along with a single trip, please provide the "first trip" info coming up within 60 days to start the annual plan. We can start the Annual Plan on the start date of the Single Trip quote option as well.
Any specific questions you would like answered along with your quote? Or any other notes you would like to provide?
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