GNI P2 Long-Term Intl Health Pg 2 of 2: Here are the last questions we'll ask. To offer you the best price available and the most accurate quote on long-term plans, the below information is necessary. (You can also Skype us at 'goodneighborinsurance' or speak with us at 480-813-9100 or toll-free 866-636-9100 for an immediate answer!) Can you tell us a little more?First Name Last Name Email* With an Organization/Company? If living in the USA: Your ZIP code Gender Male Female Your Age* Are You a US Citizen? Yes No Country of Residence Fill out this section ONLY if a spouse or children will be traveling with you.Spouse's Age Spouse's Citizenship Number of Children123456 or moreChildren's Ages Deductible Preference$100$250$500$1000$2500$5000 Check for Maternity Coverage Check for Furlough Coverage Have you or your spouse had any of the following medical conditions? Yes No Cancer Diabetes HIV / AIDS Heart Attack Mental Illness If yes, please tell us who it is and describe In which country will you be living? Desired length of coverage: (Please specify in years, months, days)Date of departure? Month Day Year Return date? Month Day Year Any further requests/comments?We're open 8:00-17:00 MST Monday-Friday. On work days we provide quotes within 24 hours, and usually much sooner than that. If your request is submitted over the weekend, we will get a quote to you before the end of the work day on Monday.CommentsThis field is for validation purposes and should be left unchanged.
