Information Request Form

Crew Insurance Assessment of Needs

The boxes marked with an * are required
*First Name		Number of crew to be covered
*Last Name		Location of owning company (country required for taxation/licensing purposes)

Vessel Name		*E-mail
*Relation to Vessel		*Confirm E-mail
Total number of crew		Telephone

Please indicate interest in each of the following benefits:


Comprehensive Medical Cover	YesNoMaybe
Wellness	YesNoMaybe
Maternity	YesNoMaybe
Hospital Daily Indemnity	YesNoMaybe
Routine Dental	YesNoMaybe
Disability Income	YesNoMaybe
Personal Accident	YesNoMaybe
Term Life	YesNoMaybe
Please indicate the estimated number of months spent in North American/Caribbean waters

Do you require Medical coverage for North American/Caribbean residents		YesNo
Do you have existing Medical insurance in place?		YesNo
Is this vessel in operation or is it a new build?		In OperationNew Build
Some plans require individual enrollment forms. Is the yacht in a position to collect such a form for each new joining crew member?		YesNo

Submitting Your Information, Please wait....