WC

Request for Quote and Application

*Marked fields are mandatory.

Personal Details

First Name:*
Last Name:*
Date of Birth:*
Gender:*

Passport Number:

Email:*
Confirm email:*
Best Contact Number:

Profession:

In what language would you like your documents ?

Agent Details

Note: Please contact your Agent for a valid agent code.

Agent Number:*

NA ----> SpouseDetails

First Name:*	Middle Name:	Last Name:*
Relationship:*	Country of Residence:*
Passport Number:	Email:*

Dependents / Additional Travelers

Do you want Coverage for your Dependents / Additional Travelers?* Yes No

Coverage Details

Country of Residence:*

Policy Type:*

Annual Multi-trip

Policy Inception Date:*

Maximum Days Per Trip:*

42 Days 90 Days

If you wish to have additional coverage options below, please select one

Would you like Option 1: Enhanced Benefits:*

Yes

Enhanced Benefit Option (Baggage, Liability, Personal Accident, Lost Documents, etc.)

Would you like Option 2: Cancellation and Curtailment:*

Yes

Please note the following:

This Policy contains specific exclusions for Pre-Existing Conditions and limitations of coverage. Please check Description of Coverage and Policy Wording to fully determine benefits covered by your Policy.
This is an International Policy. Coverage is not valid in your Country of Residence.
By accepting this coverage, you are agreeing to the terms and conditions.

Consent for Use and Disclosure of Your Health Information

The following consent for use and disclosure of your personal information does not apply to residents of the UK. Please tick this box if you are a UK resident to continue with the request for quote and application.

Application for this plan of benefits may require that you provide us with sensitive personal information about you and your enrolling dependents. In accordance with the privacy policy posted on our website, we will require your consent and the consent of those dependents you are applying for to process this application.

In the event that your application is approved we will require your continuing consent to administer your plan and this will include pre-authorization of medical services, claims administration and appeals.

Our privacy policy provides information concerning the use and disclosure of your personal information including your rights under this policy. This privacy policy is in compliance with GBG’s data protection policies and those of the European Union (EU) General Data Protection Regulation (GDPR). Throughout the year the terms of the privacy policy may be updated. You can find the most recent version at our website http://gbg.com/#/AboutGBG/PrivacyPolicy.

Your personal information, including special category or sensitive personal information such as medical and health details which you supply to the insurer may be used in many ways including, but not limited to: processing and underwriting your application for insurance, deciding whether an offer of insurance coverage can be made and on what terms, administering your policy and handling claims, and detecting and preventing fraudulent activity. Other GBG affiliates and third parties who provide services to the insurer could use your information in the same manner and further detail in respect of the transfer of your data to third parties is contained in the privacy policy.

By ticking the box “I CONSENT”, you consent to the use and disclosure of your healthcare information in accordance with our privacy policy. If you do not consent to the use and disclosure of your healthcare information GBG will not be able to evaluate your request and therefore will not be able to provide you with insurance cover. The following application should only be completed if you are willing to provide consent.

	03-May-2024
Applicant Signature	Date

I CONSENT