Global Underwriters: travel medical insurance, visitor insurance, war and terrorism coverage, and defense base act insurance.
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1-800-423-8496 | 3195 Linwood Road, Suite 201, Cincinnati, Ohio 45208, United States | 513-533-1500 | Fax: 513-533-1055

War & Terrorism Coverage from Global Underwriters

First Name*  

Middle Name  

Last Name*  

Home Address*  

  

City*  

State/Province*  

Region  
if Non US/Canada

Zip/Postal Code*  

Country*  

Telephone*  

Date of Birth*  

Height*  

  ft/in or meters

Weight*  

  lbs or kilos

Email*  

 

Employment Information

Employer*  

Occupation*  

Annual Income*  
In US Dollars

Address*  

  

City*  

State/Province*  

Region  
if Non US/Canada

Zip/Postal Code*  

Country*  

Telephone*  

 

Beneficiary Information

Beneficiary*  

Relationship*  

Contingent Beneficiary  

Contingent Relationship  

 

Policy Information

Purpose of Insurance*  

Air Travel  
Will all air travel be on regularly scheduled airlines?

Yes No

  

Desired Benefit Level*  
Not to exceed 10 times annual salary; In US Dollars

Coverage Requested  

All-Risk, 24 Hour Common Carrier Air Travel Only

Optional Coverage  

War, Acts of War or Terrorism
Nuclear, Chemical, Biological Weapons Coverage (excluded above)

Benefits Requested  

Accidental Death (AD)
Accidental Death and Dismemberment (AD+D)
AD&D + Sudden Cardiac Arrest (AD+D & SCA)

Policy Effective Date*  
When should the insurance coverage begin?

Final Day of Coverage Date*  
When is the last day you wish to be covered?

 

Travel Itinerary

Provide Detailed Travel Itinerary, Including Destination(s), Duration, and Activities

 

Health Questions

Provide Details for Any 'Yes' Answers Below

Yes No  

Have you any physical defect or infirmity?

Yes No  

Is your sight or hearing defective?

Yes No  

Have you ever suffered from any nervous or mental condition, fainting episode, blackout, fit, or paralysis of any kind?

Yes No  

Have you ever suffered from high blood pressure, a heart condition, rheumatic fever, or diabetes?

Yes No  

Have you ever suffered from a "slipped disk" or other spinal disorder, a hernia, or any rheumatic or arthritic condition?

Yes No  

Have you ever been declined or accepted on special terms for life, accident, or illness insurance?

Yes No  

Do you intend to engage in hazardous sports or any other pastimes that expose you to extra personal injury?