Mercy Ships
Top Up Insurance

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Mercy Ships Sign Up (v6) - 13 November 2024

Insured's Details (Name must match passport)

First Name:

Last Name:

Known As:

Country of Nationality:

Country of Destination:

Date of Birth:

Sex:

Family Members' Details (ONLY family members that will be on this policy)

Spouse (Name must match passport)

First Name:

Last Name:

Date of Birth:

Sex:

Child 1 (Name must match passport)

First Name:

Last Name:

Date of Birth:

Sex:

Child 2 (Name must match passport)

First Name:

Last Name:

Date of Birth:

Sex:

Child 3 (Name must match passport)

First Name:

Last Name:

Date of Birth:

Sex:

Child 4 (Name must match passport)

First Name:

Last Name:

Date of Birth:

Sex:

Child 5 (Name must match passport)

First Name:

Last Name:

Date of Birth:

Sex:

Email Address (In order to ensure your email is reachable, kindly check that you receive a notification email shortly after submission of this form)

Email Address:

Please Repeat:

Mobile Phone Number (Please provide the best mobile phone number to reach you)

Primary Mobile Number:

Alternative Phone Number:

Program Dates

Start Date:

End Date:

Payment Details

How would you like to pay?

Credit Card

Pay By Organization

When your policy is set up we will email you the payment link

Other Notes

Any comments or notes you would like to add:

How did you hear about us?

By clicking the 'Submit' button below, you are declaring that you have read, understood, and agree to the following 5 points:

I declare that I have read, understood, and agree to the terms of the Table of Benefits and Benefits Guide.
I declare that all the information supplied for all persons on this enrollment form is accurate and complete.
I understand that no cover is provided for professional sporting activities.
I understand that I may not complete this enrollment until all material facts* connected with this enrollment have been declared in full, without misstatement or misrepresentation, and have been accepted by us in writing. I understand that failure to do so will result in cover being void from inception.
I understand that pre-existing conditions are not covered. (A pre-existing condition is any disease, illness or injury, secondary or associated complaint for which you have sought or received advice, treatment, therapy, or been submitted to a special diet - whether or not the condition has been diagnosed).

* A material fact is any information that may affect our assessment or acceptance of your enrollment for insurance. If you are unsure as to whether any piece of information is a material fact, it should be declared.

To continue, please click here so we can send your policy and other relevant info like discounts and benefits. Your info is never shared outside Talent Trust, and you can opt out at any time. *

I/We agree that Third Parties can share all relevant claims information with my personal information with Talent Trust for the purposes of tracking and processing my claims. *

If you have questions, please email us, and we will get back to you as soon as we can.

info@talent-trust.com

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Mercy Ships Top Up Insurance

Insured's Details (Name must match passport)

Family Members' Details (ONLY family members that will be on this policy)

Spouse (Name must match passport)

Child 1 (Name must match passport)

Child 2 (Name must match passport)

Child 3 (Name must match passport)

Child 4 (Name must match passport)

Child 5 (Name must match passport)

Email Address (In order to ensure your email is reachable, kindly check that you receive a notification email shortly after submission of this form)

Mobile Phone Number (Please provide the best mobile phone number to reach you)

Program Dates

Payment Details

Other Notes

Success!

Mercy Ships
Top Up Insurance