IMPORTANT NOTICE: West Coast Global Insurance Services 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 Services?:
PLEASE CHECK THE TYPE OF INSURANCE COVERAGE THAT BEST FITS YOUR SPECIFIC MEDICAL NEEDS ? :
Single Trip Global Medical Insurance (Accident & Illness Travel Medical Protection)
Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)
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 Global Medical Insurance (Accident & Illness Travel Medical Protection)
Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)
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 90 days at one time.
Global Major Medical Insurance (Expatriate-International Living)
Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)
An Expatriate can be defined as an individual or family that is living 6 months or longer out of the country they hold citizenship.
Air-Evacuation Protection Only (Emergency)
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 SERVICES (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 Nationality : 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 SERVICES (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
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 Services.

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