Global Benefits USA - International Insurance

Pay By Credit Card

Please enter your credit card information. We will send you a confirmation once the payment has been processed by the insurance company. Please note that this is a secure website and only James D. Smith will see your card information. Please call 888.541.7776 or email james@globalbenefitsusa.com with any questions.

Group Policy Purchase Only

Group Name

Individual Policy Purchase Only: Name of Traveler(s)

First & Last Name(s) of Each Traveler

Policy Type

Travel Medical Insurance

Trip Protection Plan

Expatriate Health Insurance

Student Health Insurance

Other

Policy Specifics

Quoted Cost

Insurance Company

Plan Name

Medical Maximum

Deductible

Options

Travel Dates - depart & return

Start Date (Expat or Student insurance only)

Destination(s)

Additional Comments or Requests

Payment Info

First name on Card

Last name on Card

Billing Address

City

State

Zip code

Phone

Visa

MasterCard

American Express

Discover

Card Number

Card Expiration Date

Code

Comments

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