Finalise Application Share 1231/3Welcome back Please send the final information in order to complete your application. You will have an answer from us shortly! What is your gender? —Please choose an option—FemaleMale What is your / title? —Please choose an option—MrMsMrsMissDrProf And your date of birth? What is your current address? i What's your nationality? —Please choose an option—AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet Island (Bouvetoya)BrazilBritish Indian Ocean Territory (Chagos Archipelago)British Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCanadaCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyz RepublicLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Netherlands)Slovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & S. Sandwich IslandsSpainSri LankaSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrianTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUnited KingdomUnited StatesU.S. Virgin IslandsU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe What is your passport number? Your phone number Agree to be contacted by phone? YesNo Do you have any major medical problems or have you ever had an application rejected by an insurance company? i NoYes NEXT Insurance Declaration Please confirm you understand and accept our GDPR-compliant data protection policy: MedicalForNomads.com and our insurance partners only collect personal data which is relevant to your insurance cover. Failure to fully or accurately provide the personal data requested on this form may result in your insurance cover being declined and/or discontinued. For the purposes of arranging and administering your insurance cover, MedicalForNomads.com and our insurance partners share your data with our employees, auditors, contractors and consultants, parent and affiliated companies who require this information in order to be able to provide you with the insurance cover. This can from time to time include third parties that collaborate with us (such as hospitals etc) for the specific purpose of providing you with the services and insurance benefits offered. If you wish to update, access or correct your personal data collected, or have any questions about the relevant data protection policies and procedures, you can make a request at any time to either MedicalForNomads.com or the underwriting insurance company's Chief Compliance Officer. I understand and accept Your insurance application declaration: I/we declare that all information provided in this application form, including this declaration and any supporting documentation are complete and true to the best of my/our knowledge and belief. I/we understand that I/we have the right to cancel and obtain a refund of any premium under the terms of the "cooling-off" period". I/we understand that in the event of any doubt about the content of any documents provided by the insurer or the terms of any insurance provided by the insurer, I/we should obtain independent professional advice prior to the completion of this application form I hereby declare NEXT Paying For Your Medical Insurance Please select a payment method —Please choose an option—Credit/Debit card Bank transfers are fine as long as you're paying annually, although please note that your insurance coverage can't start until your payment has been received (and you're missing out on credit/debit card points/miles/cashback etc, and paying a bank transfer fee, if not paying by card, just FYI) If you have selected annual payment and would like to pay by bank transfer, please submit this application form by clicking below, and we will issue you with a provisional policy number and contact you with the bank details for payment. What credit/debit card would you like to use for payment? —Please choose an option—VisaMastercardOther type of card Please enter the 16-digit card number Card expiry date (MM/YYYY) CVC number: (3-digits on the back of the card) Please type how your name is written on the card i Please type your name one more time as a digital signature. Please enter today's date. The capital of France? We have received your application! Assuming everything has been entered correctly, there is nothing else for you to do –you will receive your international medical insurance policy documents by email shortly, directly from the insurance underwriter. If there is anything else needed from our end or anything we need to check with you we will contact you, and of course feel free to contact us at any time with any questions or comments at hola@MedicalForNomads.com. Have a great day, nomad-er what you’re doing! Δ Name: Email: Country code: Phone: Call back?: Age: Area: Cover Level: Payment Frequency: Premium Amount (USD): Optional Evacuation & Repatriation Cover: MFN Regency Medical Insurance MFN Regency Medical Insurance - Table of Benefits MFN Regency Supplementary Benefit - Nutrition MFN Regency Supplementary Benefit - Fitness MFN Regency Confirmation - Covid-19 is fully covered by this insurance Direct paymentsto the hospital Remote accessto medical professionals 24h emergencyassistance
