Global Protective Solutions - Columbia, South Carolina

Coverage is provided through a master policy issued to International Helpers (Guernsey) Trust. AON Services (Guernsey) Limited acts as trustee for this master policy. Enrollees become participants in master policy #PUSNA0801288. By paying the participation fee, coverage is afforded to the enrollee once confirmed by Custom Assurance Placements, Ltd. View the participation agreement (PDF Doc).

Leave Blank:

Enrollee/Patient Information

Enrollee/Patient:

Date of Birth:

Address:

City:

State:

Zip:

Country:

Phone:

Fax:

E-Mail:

Occupation:

Departure Date:

Return Date:

Faciity Information

Hospital Name:

Hospital Address:

City:

State:

Zip:

Country:

Type of procedure:

If your procedure is not listed, please provide details and it can be reviewed for eligibility.

Scheduled Date of Procedure:

Name of Facilitator: WorldMed Assist

If other, please provide the information below:

Name:

Address:

City:

State:

Zip:

Phone:

Fax:

E-Mail:

Enrollee/Patient Capital Sum Limit Desired

   $250,000
   $200,000
   $150,000
   $100,000
   $50,000

Emergency Evacuation Coverage

Optional Emergency Evacuation Coverage

Yes No - Please check here for Optional $50,000 Emergency Evacuation coverage. (Has to be included for both patient and companion if desired)

Beneficiary for Enrollee/Patient

Number of Beneficiaries

Family Member or/ Travel Companions:

Number of Companions

Comments

Please note ay comments or questions below:

CUSTOM ASSURANCE PLACEMENTS, LTD. DISCLAIMERS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORAMTION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRADULANT INSURANCE ACT WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (Not Applicable in CO, HI, NE, OH, OK, or VT; in DC, LA, ME, TN and VA Insurance benefits may also be denied).

INSURANCE IS NOT IN EFFECT UNTIL CONFIRMATION IS PROVIDED BY CUSTOM ASSURANCE PLACEMENTS, LTD.

Please note, this is not a major medical policy. Refer to the policy for coverage specifics.

Individual Medical Travel Insurance Quote Request