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 Medical Insurance Online Questionnaire | Mexico & Global Travel Medical Insurance Questionnaire..

Requested Start Date :

COVERAGE SELECTION

Thank you for contacting West Coast Global Insurance Services!


How This Works:

Review the different types of insurance below and select the coverage that best suits your individual or family needs. Once you submit your informal questionnaire, our team will review your information and provide you with the best carrier and plan options tailored to your needs.

How Next Steps:

This online questionnaire will guide you through a series of simple questions across multiple tabs. Your responses will help us present the most suitable coverage options efficiently.

Ready to Begin?

Select the coverage type below that suits your living or travel patterns.

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

PRIMARY RESIDENCE ADDRESS

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

Primary Applicant / Pre-Underwriting Medical Questionnaire

Is currently taking any prescribed medication(s)

NO
YES

Has been hospitalized in the last 10 years?

NO
YES

Has health changed for the positive or negative in the last 3 years?

NO
YES

Does Applicant have any Pre-Existing Conditions that have been treated by a physician in the last 3 years ?

  NO
 YES

**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**

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.

6 months of the year

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 

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    $500,000   $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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