Outreach Quote

Outreach Quote (v11) - 12 November 2024

Insured's Details

First Name:

Last Name:

Known As:

Country of Residence:

Home State if American:

Country of Destination:

Date of Birth

Sex:

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

Spouse

Date of Birth

Sex:

Child 1

Date of Birth

Sex:

Child 2

Date of Birth

Sex:

Child 3

Date of Birth

Sex:

Child 4

Date of Birth

Sex:

Child 5

Date of Birth

Sex:

Contact Information (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:

Church or Mission

Mission's Name:

Purpose of Trip

Purpose of Trip:

Program Start

Start Date:

End Date:

Plan Required:

Additional Options Note: The option, if purchased, must be applied to all dependants on the policy

All prices are quoted in US$.

Follow Me Home for Plan 1, US$35/person

Follow Me Home for Plan 1, US$35/person

This option is for members serving near their home country. It extends the medical benefit to cover up to US$50,000 or thirty (30) days (whichever comes first) should a member be evacuated to his/her home country (being the nearest country with appropriate medical facilities to the place of incident) during a medical emergency.

Note: Without this option, should a Plan 1 member be evacuated to his/her country of domicile or country of residence, all medical treatment costs incurred would become the member’s own responsibility.

US Transit for Plan 1, US$15/person

US Transit for Plan 1, US$15/person

Normally Outreach Plan 1 will not cover expenses that arise within the United States. This option will cover accident and emergency treatment in the USA for members travelling in transit through an airport in the USA to a destination outside of the USA up to US$50,000 or thirty (30) days, whichever comes first.

Zero Excess. For all plans, pricing sent with quote

Zero Excess. For all plans, pricing sent with quote

This option allows you to waive the excess for each claim. Without this option, the excess payable is US$50 for claims made outside the USA, and US$100 for claims made inside the USA.

Other Notes

Any comments or notes you would like to add:

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Outreach Quote

Insured's Details

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

Spouse

Child 1

Child 2

Child 3

Child 4

Child 5

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

Church or Mission

Purpose of Trip

Program Start

Additional Options Note: The option, if purchased, must be applied to all dependants on the policy

Other Notes

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