A S K   F O R   A   H E A L T H   Q U O T E :
PERSON(S)  TO  BE  INSURED
MR./ MRS. /other
E-MAIL
CONFIRM E-MAIL
FIRST NAME
LAST NAME
DATE OF BIRTH
Day:  Month:  Year:
TYPE OF COVER : Single
Married Couple
Family (parents and children)
ARE YOU MARRIED ? Please enter your wife's date of birth :
Day:  Month:  Year:

IF YOU HAVE CHILDREN please specify date of birth :
(if more than 3 children, contact us directly)

Day:  		Month:  Year:

Day:  Month:  Year:

Day:  Month:  Year:

STATUS :
do you benefit from :

French Social Security
Monaco Social Security (CCSS/CAMTI)
No Social Security system

IF YOU ARE under FSS or Monaco SS, do you have a preference for the level of reimbursement requested ?

(PERCENTAGES INCLUDE REIMBURSEMENT BY SOCIAL SYSTEM)

In-patient cover only
100 %
150 %
200 %
300 %
400 %

IF YOU DON'T HAVE ANY SOCIAL SECURITY please specify :

Territorial limits of cover :

Worldwide
Worldwide
(excluding USA, Canada, Japan, Israel, Switzerland)
 Europe
France and country of origin
France ONLY

Cover requested :

In-patient cover only (hospital/clinic)
Out-patient cover (Doctors, Medecine, Exams etc..)
Dental
Optical
Use this box for any questions that you may have for us :
Please send me a free, no obligation, quotation based on the above :