Foreign Travel Insurance Request

1 Personal

2 Schedule

3 Travelers

4 Emergency

Personal Information
A field marked with a red asterisk is required.
Primary traveler*
Prefix First Last
Area of ministry / school*
An e-mail notification will be sent to the area of ministry administrator or school business manager for approval.
Other*
Include your area of ministry or school.
Mailing address*
Address line 1 Address line 2 City State/Province Zip/Postal code Country
E-mail*
Enter e-mail Confirm e-mail
Cell phone*
Phone options*
Select ALL that apply.
- You may send TEXT messages to this number.
- You may send via Whats App to this number.
- You may voice call this number.
- You may ONLY voice call this number.
- Cell plan includes international coverage.

Travel Schedule
Is this trip booked through Fox Travel?*
If other, what travel agency was used and why.
- Yes
Select (+) to add a new row for each destination.*
From date (mm/dd/yyyy) To date (mm/dd/yyyy) Country City Purpose
Modes of travel*
Security precautions taken for trip*

Names of Travelers
Including yourself, enter first and last name of all travelers. Select (+) to add a new row.*
File upload option
- I would prefer to upload a file.
Upload file with names of all travelers*
File extensions allowed: doc, docx, pdf
Accepted file types: doc, docx, pdf.
Number of Travelers
Enter number*
Missionaries Volunteers Students Chaperones Spouse Children Other
If other, please specify

Emergency Contact Information
Emergency contact name*
First Last
Relationship*
Address
Address line 1 Address line 2 City State/Province Zip/Postal code Country
E-mail*
Phone*
Phone options*
Select ALL that apply.
- You may send TEXT messages to this number.
- You may send via Whats App to this number.
- You may voice call this number.
- You may ONLY voice call this number.
Data Privacy & Permission*
I AGREE with the terms of the WELS Privacy Policy.
NOTE TO EU RESIDENTS:

By submitting this form you consent to any and all information you provide and submit via the site being sent to the United States of America. The United States has not sought nor received a finding of “adequacy” from the European Union under Article 45 of the GDPR. WELS relies on derogations for specific situations as set forth in Article 49 of the GDPR. You are also informed that the United States presently does not have an adequate level of personal data protection as determined by the European Commission’s adequacy decision on October 6, 2015 (case c-362/14) and articulated in the European Union’s General Data Protection Regulation and has not received a similar designation of adequacy by any other foreign data protection authority. You agree to the transfer of your data and personal data to the United States, however, to be used in accordance with WELS Privacy Policy.

From date (mm/dd/yyyy)	To date (mm/dd/yyyy)	Country	City	Purpose