Alpha Quote

Alpha Quote (v14) - 13 November 2024

Insured's Details

First Name

Last Name

Known As

Country of Nationality

Country of Destination

Date of Birth

Sex

Family Members (ONLY family members that will be on this policy)

Spouse

Date of Birth

Sex

Child 1

Date of Birth

Sex

Child 2

Date of Birth

Sex

Child 3

Date of Birth

Sex

Child 4

Date of Birth

Sex

Child 5

Date of Birth

Sex

Contact Information (In order to ensure your email is reachable, kindly check that you receive a notification email shortly after submission of this form)

Email Address

Please Repeat

Church or Mission

Mission's Name

Program Start

Start Date

Additional Options (Some options have a waiting period. Please refer to the Options Page for details)

All prices are quoted in US$ per year.

Vision Care

$78 per person

Dental

$367/person

Travel Cover

$30 per adult

Pregnancy Cover

$4,000 benefit, $696 / $10,000 benefit, $957 / $25,000 benefit, $957 (10% co-insurance applies)

Travel costs of insured members to be with a close relative who is at peril of death or who has died

$384 per policy

Personal Accident

$212 per adult

Restricted Territories Cover

This option reduces your Alpha premium by 25%
Please read this clarification if you are considering this option

Non-Emergency Travel

4% of total policy premium

Crisis Assistance Program (CAP)

$90/year per adult, $75/year for each dependent child

Additional Chronic Conditions Cover

$1,136 per adult and $385 per child

Other Notes

Any comments or notes you would like to add

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Alpha Quote

Insured's Details

Family Members (ONLY family members that will be on this policy)

Spouse

Child 1

Child 2

Child 3

Child 4

Child 5

Contact Information (In order to ensure your email is reachable, kindly check that you receive a notification email shortly after submission of this form)

Church or Mission

Program Start

Additional Options (Some options have a waiting period. Please refer to the Options Page for details)

Other Notes

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