Travel Insurance Questionnaire
Answer a few questions and receive a quote within 24-48 hours!
Travel Agent Name: (If applicable.)
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Thank you for submitting your client for a quote!
Primary Travelers Name & DOB: (Example: John Doe, 09/09/1963.) The coverage for all Travelers is the same. The Primary Travelers is the point of contact and policy owner.
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Destination(s) Clients are Traveling:
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If more than one location please provide them all.
Total Cost of the Trip:
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Include flights, hotel, rental car, etc.
Date of the initial deposit made on the trip:
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(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.)
Supplier: (Example, Delta Vacations, Apple, Classic, etc.)
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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 Phone Number:
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Primary Travelers Email Address:
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Primary Travelers Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates of Travel:
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Secondary Travelers Name(s) & DOB: (Example: Julia Doe, 10/10/1965)
Secondary Travelers Name(s) & DOB:
Secondary Travelers Name(s) & DOB:
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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