| 01 |
Name as given in passport for all proposed insured |
Format: First name, Middle Name, Last Name |
| 02 |
Date of Birth as given in passport - for all proposed
insured |
Format: month / date / year |
| 03 |
Passport Number of all proposed insured |
|
| 04 |
Passport Issuing Country |
|
| 05 |
Home Country address of proposed insured |
Preferably with postal code |
| 06 |
Correspondence address in USA including Zip code |
If applicable |
| 07 |
Phone Nos. - Home, Work and/or Cell phones |
If applicable |
| 08 |
Email address |
Should receive html files |
| 09 |
Beneficiary for Accidental Death and Dismemberment benefit |
Format: First name, Middle Name, Last Name |
| 10 |
Relationship of beneficiary to proposed insured |
|
| 11 |
Date of departure from Home country |
Format: mm/dd/yyyy |
| 12 |
Coverage start date |
Format: mm/dd/yyyy |
| 13 |
Coverage end date or No. of months |
Format: mm/dd/yyyy |
| 14 |
Credit card No. and Security code |
American Express, Discover, Master Card, Visa |
| 15 |
Credit card expiration date |
Format: mm/dd/yyyy |
| 16 |
Name as given in credit card |
|
