Short-Term & Travel Insurance Questionnaire

1

Country of Departure:* This field is required.

2

Country of Destination:* This field is required.

3

Do you have exact Travel Dates?* This field is required.

Yes

No

4

What is your travel BEGIN DATE?* This field is required.

Date

5

What is your travel END DATE?* This field is required.

Date

6

NOT SURE of your exact travel dates?

Week

Month

Year

7

Please Enter Your Name* This field is required.

8

Email* This field is required.Your Email

9

Gender* This field is required.Your Gender

Male

Female

10

Date of Birth* This field is required.Your DOB

Date

11

Passport Issue* This field is required.The Country of Your Passport Issuance

12

Do you want to add a Spouse / Partner?* This field is required.

Yes

No

13

Your Spouse/Partner's Name* This field is required.

14

Email* This field is required.

15

Gender* This field is required.

Male

Female

16

Date of Birth* This field is required.

Date

17

Passport Issue* This field is required.

18

Do you want to add Children* This field is required.

Yes

No

19

No. of Children* This field is required.Please select below,

20

+ Child #1 Information* This field is required.

21

Gender* This field is required.+ Child #1 Information

Male

Female

22

Date of Birth* This field is required.+ Child #1 Information

Date

23

Passport Issue* This field is required.+ Child #1 Information

24

+ Child #2 Information* This field is required.

25

Date of Birth* This field is required.+ Child #2 Information

Date

26

Gender* This field is required.+ Child #2 Information

Male

Female

27

Passport Issue* This field is required.+ Child #2 Information

28

+ Child #3 Information* This field is required.

29

Gender* This field is required.+ Child #3 Information

Male

Female

30

Date of Birth* This field is required.+ Child #3 Information

Date

31

Passport Issue* This field is required.+ Child #3 Information

32

+ Child #4 Information* This field is required.

33

Gender* This field is required.+ Child #4 Information

Male

Female

34

Date of Birth* This field is required.+ Child #4 Information

Date

35

Passport Issue* This field is required.+ Child #4 Information

36

Interested in adding enhanced benefits to your quote?

Trip Cancellation

Pre-existing conditions upgrade

Tech protection

Pet protection

Amateur sports (recreational sports)

No

37

Additional Comments