West Coast Global Insurance: - International Expat Health Application | Travel Medical Application
Contact: Jason Wagner
office: 818-788-5353
IMPORTANT NOTICE: West Coast Global Insurance wants to take the time to understand our clients Specific Health & Medical needs. This is why we created this brief questionnaire. We understand that not every client is the same and neither are the Insurance carriers. Each Insurance Carrier offers plans with different requirements and benefits, some better than others and we have done our homework. We look forward to learning a little more about you so we may present our BEST options of coverage. Please answer these questions below and we look forward to earning your business.
How did you hear about West Coast Global Insurance?:
    Please check the type of Insurance Coverage that Best Fits your Specific Medical Needs ? :

Single Trip Travelers Insurance Protection (Accident and Illness including Air-Evacuation)
     A Single Trip protection plan can be defined by an individual or family that is traveling out of their home country from 5 days to 365 days with the plan of returning to the country they hold their citizenship.
Multi-Trip Travelers Insurance Protection (Accident and Illness including Air-Evacuation ~ Annual Plan)
     A Multi Trip protection plan can be defined by an individual or family that takes multiple trips in one year out of their home country. No one trip out of their home country is longer than 45 days at one time.
Expatriate Health Insurance Protection ~ Major Medical & Catastrophic (International Living)
     An Expatriate can be defined as an individual or family that is living a minimum of 6 months out of the country they hold their citizenship.
Air-Evacuation Protection Only
     Air-Evacuation can be defined as a plan that provides an individual or family an Air Ambulance in the event of a catastrophic medical emergency. No medical coverage is provided.
How many More Members not including yourself are you Interested or Requesting Coverage for?
West Coast Global Insurance (Getting to Know you ~ Questionnaire)
Applicant 1
Primary Applicant First Name : Primary Applicant Last Name :
Date of Birth : , Age :
Height : Feet Inches Weight : Pounds
Primary Applicant Citizenship : Gender :
Best Phone Number : Secondary Phone Number :
Best eMail : Secondary eMail :
Address in U.S. or Canada : City :
State or Province : Postal Code :
West Coast Global Insurance (Understanding the Needs of our Clients)
Is Applicant #1 currently taking any prescribed medication(s)?    Yes     No
Has Applicant #1 been Hospitalized in the last 10 years ? Yes   No
Has Applicant number 1's health changed for the positive or negative in the last 3 years? Yes   No
Please provide details of change
Does Applicant #1 have any Pre-Existing Conditions that have been treated by a physician in the last 3 years ? Yes     No
**If you answer YES to having a Pre-Existing Condition this does not automatically decline you for coverage. ALL carriers and plans offer different underwriting guidelines.It is important that we understand our clients medical history because these questions will be asked on the formal application. Our Goal is to find our clients the BEST Coverages and Pricing for their International Medical needs**
Please tell us what is most important to you or if there is anything extra you feel we should know please add those comments below.We look forward to working with you.West Coast Global Insurance.

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Applicant's Statement
I have read the above application and any attachments. I declare that the information I provided is true, complete and correct to the best of my knowledge & belief. This information is being offered to the company as an inducement to issue the policy for which I am applying and no coverage is offered at this time.