West Coast Global InsuranceServices

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West Coast Global Insurance Global Health Insurance Online Questionnaire | Mexico Travel Medical Insurance Questionnaire.

West Coast Global Insurance Services

Ca.Lic. #0E50745

USA - (818) 788-5353

Mex - 01 (800) 099 0614

REQUEST QUOTE - Global Health Insurance Online Questionnaire | Mexico Travel Medical Insurance Questionnaire.

Requested Start Date :

Thank you for contacting West Coast Global Insurance Services.

We have streamlined our online informal questionnaire to help expedite getting in front of you the information you came to West Coast Global Insurance to secure. Due to the amount of calls we receive on a daily basis, we request our new clients seeking insurance protection to take just a few minutes and provide us answers to our most popular questions.

Please review each type of insurance below and select the coverage type that meets your individual/family insurance needs. We are of course here to help answer specific questions after we receive your submitted informal questionnaire.

DIRECTIONS

This Online Questionnaire will prompt you through each tab asking you basic questions that will provide our service team just enough information so we may present to you the best carrier and plan options that meet your individual/family needs.

Ready, Set, >> Please select the coverage type below you would like to secure or learn more about!!

GLOBAL HEALTH INSURANCE - Major Medical Insurance (Expatriate-International-Nomad-Living):

An Expatriate can be defined as an individual or family that is living 6 months or longer out of the country they hold citizenship.
Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)

SINGLE TRIP – Travel Medical Insurance (Accident & Illness):

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.
OPTIONAL - (Not all Insurance Carriers Provide Trip Delay in the event you are Quarantined)
Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)

MULTI TRIP – Travel Medical Insurance (Accident & Illness):

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.
Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)

TRIP PROTECTION (Vacation Investment Protection) & TRAVEL MEDICAL (Accident & Illness):

An individual or family seeking financial protection for non-refundable vacation/trip costs.
(Includes Travel Medical, Trip Delay in the event you are Quarantined)
Emergency Air Evacuation included: (Transportation to the Nearest Facility that can Treat the Medical Emergency)

AIR-EVACUATION (Emergency-Hospital of Choice):

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.

Yellow Fields are Required*

PRIMARY APPLICANT

BENEFICIAL OWNERS DETAILS

HEIGHT AND WEIGHT

CONTACT DETAILS

If you received this questionnaire from an eMail sent by our office, please be sure to enter the same eMail address. This will assure your questionnaire submission is properly linked to your client profile.

Do you have a Mexico Phone Number? YES   NO

I have Whats App? : YES   NO  

PRIMARY RESIDENCE ADDRESS

Enter the physical address of the location where you reside, not the destination address you are traveling to.

Primary Applicant General Questionnaire

I currently have an Active Major Medical Insurance Plan in my Home Country?

NO
YES

My Age is 65 or older and I am a U.S. Citizen, enrolled in Medicare?

NO
YES

I am a U.S. Citizen or Legal Resident of the United States?

NO
YES

Additional Comments Section:

ADDITIONAL FAMILY MEMBERS

Would you like to include any additional Family Members?

NO YES

COVERAGE QUESTIONNAIRE

Please provide your Monthly Medical Insurance Budget?
This is only a point of reference, so we may present to you the BEST Global Insurance Carrier options that meet your Individual needs and Financial Monthly Budget.

$    $

I will physically be in this country for this amount of time annually?
This is only a point of reference, so we may present to you the BEST Global Insurance Carrier options that meet your Individual needs and Financial Monthly Budget.

Please select the Deductible that Fits your Individual Needs?
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

$250   $500  $1,000  $2,500 
$5,000  $10,000  $20,000 

I currently have an Air Evacuation plan in place now ?

NO YES

I understand that by choosing Air Evacuation ONLY, there will be Zero protection for Medical Expenses incurred prior to the Emergency Air Evacuation:

Yes

(If you are seeking medical coverage as well, please select a Single or Multi Trip plan option. Please note that both Single & Multi Trip plans do NOT provide Hospital of Choice.)

Requested Coverage Start & End Dates?

  

Requested Coverage Start Date?

What country or countries will you be visiting?

+

IMPORTANT: Securing your insurance prior to leaving your home country is required for most global travel insurance plans. Failure to secure your insurance prior to your trip will limit the plan options available.
It is important that we know this answer to insure you are presented a plan option based on your physical location.

We recommend that your insurance is secured a minimum of 48 hours prior to leaving your home country, however travel insurance can be purchased anytime. (Restrictions May Apply)

I am physically located in the destination country I am requesting travel medical coverage for?

NO YES

I have not yet left on my trip & I will be purchasing this insurance prior to leaving my home country?

NO YES

Please provide the resort, hotel or development name of your travel destination?

I am currently located in the country I am requesting medical coverage for?

NO YES

The maximum amount of days I will be travelling outside my home country will be NO more then?

Travel Medical Insurance Benefits are Included up to Policy Limits on All Plans.

Please answer YES, if these additional coverages are important to you.

Is Trip Protection Coverage Important to you?

Vacation Investment Insurance Protection for Non-Refundable Trip Costs.

NO     YES

Is Cancel for Any Reason coverage Important to you?

NO      YES

Provides reimbursement for the percentage of the prepaid, non-refundable, forfeited payments you paid for your trip, if you cancel your trip for any reason not otherwise covered by the policy. Must be purchased with the initial policy and within 21 days of the initial trip deposit date, and the full, non-refundable trip cost is insured.

Is Trip Delay Coverage Important to you?

NO      YES

Provides coverage for accommodations due to a covered Trip Delay in the event a covered person requires to be quarantined due to testing positive for Covid.

COVERAGE PREFERENCES

Is insurance Coverage Important to you in the United States?
Premium is reduced up to 50% if coverage in the United States is NOT required

NO         YES

Are you looking for a plan that will cover you for Annual Doctor Visits and Preventative Care?

NO         YES

Are you looking for a Catastrophic Only Plan?

NO         YES

CARRIER MAXIMUM LIMITS OF COVERAGE

ANNUAL MAXIMUM BENEFIT:
What is ANNUAL Maximum Benefit?
Annual limits are the total benefits an insurance company will pay in a year while an individual is enrolled in a particular health insurance plan.

$350,000   $1,000,000  $1,500,000  $2,000,000 
$2,500,000  $3,000,000  $4,000,000   $5,000,000 
$8,000,000  $10,000,000  Unlimited 

LIFETIME MAXIMUM BENEFIT:
What is LIFETIME Maximum Benefit?
Lifetime maximum benefit – or maximum lifetime benefit – is the maximum dollar amount a health plan will pay in benefits to an insured individual during that individual’s lifetime.

$500,000   $1,000,000  $3,000,000  $5,000,000 
$7,000,000  $8,000,000  $9,000,000 

A FEW MORE QUESTIONS TO UNDERSTAND THE SCOPE OF YOUR EXPSOURE TO RISK IN MEXICO?

Final Expense Insurance – I am interested in a Final Expense Insurance policy. This type of Life Insurance is a low limit death benefit with limits of coverage starting at $50,000 USD. This type of policy provides financial relief so loved ones are not burdened with the funeral/burial costs.

NO         YES

Global Life Insurance – I am interested in a Life Insurance policy to safe guard my family or business partner/s to pay off any outstanding loans that are on my property. Limits from $50,000 USD to $10,000,000 USD. (A medical exam may not be required depending on limit of coverage selected – Easy Underwriting)

NO         YES

Mexico Auto, Truck, RV, Motorcycle, UTV, ATV Insurance (U.S., Canadian & Mexico Registered) - I own or plan on purchasing a vehicle that will be in the republic of Mexico and would like to know more about Mexico auto insurance & liability protection in Mexico.

NO         YES  

Mexico Home/Condo Insurance - I am interested in protecting my property in Mexico against risks such as Fire, Theft, Hurricane, Earthquake & 3rd Party Mexican Liability.

NO         YES

Mexico/Global Boat & Yacht Insurance - I own or plan on purchasing a boat/yacht and would like to know more about watercraft insurance & liability protection in Mexico. (California, Mexico & Global Navigational Limits Available – No Hurricane Season Black Out Dates)

NO         YES

YOU ARE ALMOST FINISHED!!

Please provide us any additional details that you would like your file manager to know about you, your family members or the Global Health Insurance you are seeking to secure?

How did you hear about West Coast Global Insurance Services? (This is very helpful information for us. THANK YOU!)

DIGITAL SIGNATURE

I acknowledge that West Coast Real Estate & Insurance, Inc., doing business as West Coast Global Insurance Services, does not guarantee any coverages and has presented this informal application/questionnaire solely for the purpose of collecting general information. I comprehend that the submission of this informal application/questionnaire does not constitute insurance coverage for either myself or the insured item for which I am seeking information.

I am aware that the coverage limits I have requested may be subject to change upon the generation of a formal quote by an insurance company. It is my responsibility to thoroughly review the coverages and policy conditions at that time. I confirm that I have read the foregoing application/questionnaire, along with any attached documents, and declare that the information provided therein is true, complete, and correct to the best of my knowledge and belief. I understand that this information serves as an inducement for the company to consider issuing an insurance policy, and no coverage is currently being offered.

I acknowledge that West Coast Real Estate & Insurance, Inc., DBA West Coast Global Insurance Services, will be in communication with me to further assist with my insurance needs. I hereby grant my consent to receive telephone calls, text (SMS & MMS) messages, and email communications. I understand that providing consent is not a condition of purchase, and standard message and data rates may apply. For more information on how your data is handled, please visit our Privacy Policy. (PRIVACY POLICY)
Checking this box serves as my digital signature.

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