International Group Medical Insurance: Missionary, Individuals, Group, Corporate

Group Outreach Travel: Medical Census Form

Group Information

Fill in your group or organizations contact information:

Group Name: *

Contact Name: * First * Last

* Day Phone: * Email:

* Destination: * Desired Benefit Amount:

Deductible: Method of Delivery:

Group Address:

Street Address:

Address continued:

City State Zip

Group Members Traveling

Minimum 5 persons - up to age 69 - please call 1-800-576-2674 if over Age 69

Full Name: *

Date of Birth: *

Age: *

Beneficiary: (Not Mandatory)

Departure Date: *

Return Date: *

Group Member:

Full Name: *

Date of Birth: *

Age: *

Beneficiary: (Not Mandatory)

Departure Date: *

Return Date: *

Group Member:

Full Name: *

Date of Birth: *

Age: *

Beneficiary: (Not Mandatory)

Departure Date: *

Return Date: *

Group Member

Full Name: *

Date of Birth: *

Age: *

Beneficiary: (Not Mandatory)

Departure Date: *

Return Date: *

Group Member:

Full Name: *

Date of Birth: *

Age: *

Beneficiary: (Not Mandatory)

Departure Date: *

Return Date: *

Qualify for Special Pricing:

Group Total Age:

÷ Number of people in the group

= Average Age of Group: