Michael W. Smith Agency

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Global Health

If you live outside of Minnesota click on the Agency Link System

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International Medical Group Click the IMG graphic for information, rates and to apply for International Medical Insurance.   Coverage while you are outside your home country, for traveling or Foreign Nationals visiting the U.S.

International - World Wide - Global

Medical Health Insurance Coverage

Medical Health Insurance Coverage for anyone traveling outside their home country. Foreign Nationals visiting the USA, Missionaries, US Citizens traveling outside the US. Long or Short Term Coverage available at affordable rates. Coverage from 15 days up to 3 years.

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Health Care Rate Quote Request Form

This is a request for a quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Insurance rates are subject to change.

Name

Address

E-mail

Phone

Fax

 

Applicant's Date of Birth

Sex

U.S. Citizen

Yes No

Social Security Number

Yes No

Spouse's Date of Birth

Sex

 

Please Enter the Age of Each Dependent Child to be Covered

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

 

Choose the Type of Coverage Needed

 

Additional Comments

 

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Since 1978
Michael W. Smith Agency

Copyright © 2000 Michael W. Smith Agency
Last modified: April 06, 2008