Travel Insurance Intake Form

First Name

DOB
(mm/dd/yy)

Citizenship

Traveler 2

Traveler 3

Traveler 4

Traveler 5

Traveler 6

Travel Insurance Intake Form
Hey there!

Thanks for reaching out about travel insurance for your upcoming trip!

To make sure I find appropriate coverage options and provide you with an accurate quote tailored to your specific needs, please take a few moments to fill me in on some of the specifics below.

Once I receive this info, I should be able to get a quote turned around rather quickly and back to your inbox in no time!

For any questions, please don't hesitate to reach out to me directly. You can find all my contact info at the end of this form.
First Name of Primary Traveler*
Last Name of Primary Traveler*
Date of Birth (DOB)*

MonthDayYear
Your Age Today*
E-mail*
example@example.com
Phone Number*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Citizenship*

First and Last names of all covered travelers for your quote, their DOB, Home Address, and Citizenship (only if different from the Primary Traveler's address)

Trip Start Date*

MonthDayYear
For annual policies, enter the date you want the policy to begin
Trip End Date

MonthDayYear
If requesting an annual policy, leave this blank

Are there any staggered travel dates for any of the additional travelers? If so, please list their travel dates

Rows	Start Date (mm/dd/yy)	End Date (mm/dd/yy)	Destination
Traveler 2
Traveler 3
Traveler 4
Traveler 5
Traveler 6

Date that First Deposit was Made on Trip

MonthDayYear
If no deposit has been made yet, leave blank
Total dollar cost spent on the trip / value you'd like to insure?
Leave blank if you don't want Trip Cancellation or Trip Interruption coverage
Countries you plan to visit on your trip(s)*
For annual policies, list known countries or type "annual"
Specific suppliers that you'll be using for your trip(s)*
For example, Delta Airlines, Expedia Tours, Hyatt Hotels, etc...
Which coverage types are most important to you*

Trip CancellationTrip DelayTrip InterruptionMissed ConnectionBaggage Loss, Theft, or DamageBaggage DelayEmergency Medical and Dental ExpensesEmergency Medical Transportation or Evacuation24/7 Crisis Hotline Assistance"Cancel for Any Reason" Coverage
Anything else you'd like to share that wasn't covered above?
Tell us who referred you
If you made it this far, it's probably safe to say that you've got these questions covered!

However, if this whole thing is reading like a 9th grade physics textbook, don't hesitate to schedule some time on my calendar for a complimentary consultation to talk through your questions and get a Travel Insurance quote in real-time.

Travel Insurance Consultation Booking Calendar Link

Tap the link above, find a time that works for you, hit submit, and we'll be chatting in no time! 💬 💬 💬
_____________________
Patrick Sugarman

thepointspage.com
Register for our Newsletter
Email me Here
Please note that in order for you to benefit from pre-existing coverage your policy must be purchased in compliance with the terms and conditions set forth in said policy, which can differ depending on the insurance company offering coverage. It is recommended that you fully read all terms and conditions of any quote for coverage to ensure your coverage is adequate and as-expected.

It is also important to understand that you do not have coverage until your quote is finalized and a policy produced after you have paid the policy premium.
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