International Medical Travel Form

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Pre-Enrollment Questionnaire for International Medical Travel

No matter where your travels take you, you deserve the confidence of knowing your health care is in trusted hands. At COLLOCAMOTION, we've carefully partnered with leading international health providers to offer our clients comprehensive coverage options. Our partners have been ensuring the well-being of travellers worldwide for decades.

First name

Last name

Email

Phone

When will you be traveling?

Travel Start Date

Travel End Date

What is the primary country where coverage is needed?

Primary Insured

Age:

Date

Please enter age at the time of coverage.

Gender

Male

Female

Citizenship:

Residence and Postcode

Add Spouse

Age:

Date

Gender

Male

Female

If all the trip participants live at the same address, you should only write: same as above

Citizenship:

Residence and Postcode:

Add kids

1. Age:

Date

Gender

Male

Female

Citizenship:

2. Age:

Date

Gender

Male

Female

Citizenship:

3. Age:

Date

Gender

Male

Female

Citizenship:

Residence and Postcode:

4. Total Trip Cost

5. First Payment Date

6. How many countries will you be visiting including countries visiting by cruise or by plane?

7. What connecting countries will your flight or cruise use before getting to your final trip?

We kindly request that you provide us with information regarding the relationship between each individual who will be traveling. Understanding the dynamics of your group helps us tailor our services to better suit your needs.

Additionally, some carriers cover most pre-existing medical conditions if you have a primary health plan in the USA, which can be either ACA, Medicare or employer sponsored group health plan.

Thank you for your cooperation. We look forward to assisting you with your travel insurance needs.

Warm regards,

COLLOCAMOTION Team

Disclaimer

The information contained within this site is the intellectual property of COLLOCAMOTION Financial & Wellness, LLC and is for informational purposes and a solicitation of insurance. It is not intended to diagnose, cure, treat or prevent any health problem – nor is it intended to replace the advice of a physician. Licensed Agents affiliated with COLLOCAMOTION agree to comply with the State Department of Financial Services and CMS regulations for Medicare, Commercial, and Individual health insurance. A licensed insurance broker is contracted with multiple carriers offering Medicare Advantage and Prescription Drug plans each with a Medicare contract. Enrollment depends on contract renewal. You'll be contacted by a licensed insurance broker. COLLOCAMOTION reserves the right to use any photograph/video taken at any public event sponsored by COLLOCAMOTION. Media may be used in publications or social media.

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