1 Holder & Co-Holder

2 Plan & Beneficiaries

3 Pets

4 Payment

5 Medical Questions

6 Review

👤

Titular & Co-Titular

Complete la información del titular y co-titular para comenzar.

Holder information

First Name

Middle Name

Last Name

Birthdate

Age

Birth Country

Gender

Marital Status

Language

Dirección residencial

Address

City

State

Address Street 2 (optional)

Zip Code

Country

Información de contacto

Teléfono

Other Phone

I wish to designate myself as a beneficiary in this plan. Check if you want to add as beneficiary.

Co-Holder Information

First Name

Middle Name

Last Name

Phone

Business Phone

Address

City

State

Address Street 2

Zip Code

Country

I wish to designate the co-holder as a beneficiary in this plan. Check if you want to add as beneficiary.

📋

Plan & Beneficiarios

Plan de cobertura y lista de beneficiarios.

Planes de Cobertura

AMERICA PLAN

$39/mo

(2 beneficiaries)
USA + LATAM

SERENITY PLAN

$49/mo

(4 beneficiaries)
USA + LATAM

SERENITY PLUS PLAN

$69/mo

(8 beneficiaries)
USA + LATAM

Lista de Beneficiarios

Número de beneficiarios

1

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

2

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

3

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

4

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

5

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

6

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

7

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

8

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

9

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

10

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

🐾

Mascotas

Agregue información de sus mascotas si desea incluirlas.

Número de mascotas

1

Type

Race

Age

Weight (pounds)

Name

2

Type

Race

Age

Weight (pounds)

Name

3

Type

Race

Age

Weight (pounds)

Name

4

Type

Race

Age

Weight (pounds)

Name

💳

Pago

Seleccione el método de pago y revise su orden.

Forma de Pago

Monthly Bi-Annual Annual 3 payments

Descuento

Selección de Plan

America Serenity Serenity Plus

	Riders \| Add-ons	Precio
	Repatriación (cuerpo a latam) + Asistencia Funeraria en Viaje	$15.00
	9th Beneficiary	$15.00
	10th Beneficiary	$30.00
	2nd Pet	$9.00
	3rd Pet	$8.00
	4th Pet	$7.00

Precio

Cargo Unico

Adicional

Subtotal

Descuento

Total a Pagar

Fecha de Pago

Próximo Pago

Agent Code

Agent Name

Agent Email

Observations

📋

Revisión Final

Por favor, verifique toda la información antes de enviar la solicitud.

👤

DATOS DEL TITULAR

NOMBRE -

SEGUNDO NOMBRE -

APELLIDO -

FECHA DE NACIMIENTO -

EDAD -

GÉNERO -

TELÉFONO -

OTRO TELÉFONO -

EMAIL -

DIRECCIÓN -

CIUDAD -

ESTADO -

CÓDIGO POSTAL -

PAÍS -

PAÍS DE NACIMIENTO -

ESTADO CIVIL -

👥

DATOS DEL CO-TITULAR

NOMBRE -

SEGUNDO NOMBRE -

APELLIDO -

EMAIL -

TELÉFONO -

OTRO TELÉFONO -

DIRECCIÓN -

CIUDAD -

ESTADO -

CÓDIGO POSTAL -

PAÍS -

📋

PLAN & BENEFICIARIOS

PLAN SELECCIONADO -

CANTIDAD DE BENEFICIARIOS -

#	NOMBRE COMPLETO	FECHA DE NACIMIENTO	EDAD	PARENTESCO	CIUDAD/ESTADO	NACIONALIDAD	TELÉFONO	EMAIL
1	-	-	-	-	-	-	-	-
2	-	-	-	-	-	-	-	-
3	-	-	-	-	-	-	-	-
4	-	-	-	-	-	-	-	-
5	-	-	-	-	-	-	-	-
6	-	-	-	-	-	-	-	-
7	-	-	-	-	-	-	-	-
8	-	-	-	-	-	-	-	-
9	-	-	-	-	-	-	-	-
10	-	-	-	-	-	-	-	-

➕

RIDERS / ADD-ONS

#	NOMBRE	PRECIO	ESTADO
1	-	-	-
2	-	-	-
3	-	-	-
4	-	-	-
5	-	-	-
6	-	-	-

🐾

MASCOTAS

#	TIPO	NOMBRE	RAZA	EDAD	PESO
1	-	-	-	-	-
2	-	-	-	-	-
3	-	-	-	-	-
4	-	-	-	-	-

💊

PREGUNTAS MÉDICAS Y OBSERVACIONES

1. Has any beneficiary been diagnosed by a physician with a terminal illness, or received a limited life expectancy prognosis, including, but not limited to, a life expectancy of less than twenty-four (24) to thirty-six (36) months?

2. Is any beneficiary currently hospitalized, admitted to an intensive care unit (ICU), under palliative care or hospice care, in a long-term care facility, or has any beneficiary been referred, recommended, or medically instructed by a physician for admission, evaluation, treatment, or follow-up under any of these care settings due to a serious, chronic, advanced, terminal, or high-risk medical condition?

3. Has any beneficiary been diagnosed with, treated for, or suffered from any of the following conditions within the last twenty-four (24) months: cancer, whether active or under treatment; severe heart disease, including, but not limited to, heart attack, heart failure, or other cardiac conditions; kidney failure or dialysis; stroke or cerebrovascular accident; severe pulmonary disease, including, but not limited to, advanced COPD, pulmonary fibrosis, or oxygen dependency; neurodegenerative disease, including, but not limited to, advanced Alzheimer’s disease, advanced Parkinson’s disease, ALS, or similar conditions; cirrhosis; advanced liver disease; organ transplant; or immunosuppressive treatment?

4. Does any beneficiary currently suffer from a chronic or progressive illness that is in an advanced stage, has required recurrent hospitalizations within the last twelve (12) months, or is considered medically unstable or decompensated?

5. Does any beneficiary currently present serious undiagnosed symptoms, including, but not limited to, unexplained weight loss, severe breathing difficulty, persistent bleeding, or disabling pain; or is any beneficiary undergoing medical testing due to suspicion of a serious illness; or is the Plan Holder aware that any beneficiary must undergo, or is being evaluated for, any medical procedure, surgical intervention, hospitalization, or specialized treatment, including surgeries, biopsies, oncology treatments, or any other invasive or non-invasive procedures?

Observaciones:

💳

DETALLES DE PAGO

MÉTODO DE PAGO -

PRECIO -

CARGO ÚNICO -

ADICIONAL -

DESCUENTO -

PRÓXIMO PAGO -

FECHA DE PAGO -

TOTAL DE HOY $0.00

💼

INFORMACIÓN DEL AGENTE

CÓDIGO DEL AGENTE -

NOMBRE DEL AGENTE -

EMAIL DEL AGENTE -

🔒 Su información está protegida y es 100% confidencial.

Share 1	Price	Payment Date
Share 2	Price	Payment Date
Share 3	Price	Payment Date

#	NOMBRE COMPLETO	FECHA DE NACIMIENTO	EDAD	PARENTESCO	CIUDAD/ESTADO	NACIONALIDAD	TELÉFONO	EMAIL
1	-	-	-	-	-	-	-	-
2	-	-	-	-	-	-	-	-
3	-	-	-	-	-	-	-	-
4	-	-	-	-	-	-	-	-
5	-	-	-	-	-	-	-	-
6	-	-	-	-	-	-	-	-
7	-	-	-	-	-	-	-	-
8	-	-	-	-	-	-	-	-
9	-	-	-	-	-	-	-	-
10	-	-	-	-	-	-	-	-

#	NOMBRE COMPLETO	FECHA DE NACIMIENTO	EDAD	PARENTESCO	CIUDAD/ESTADO	NACIONALIDAD	TELÉFONO	EMAIL
1	-	-	-	-	-	-	-	-
2	-	-	-	-	-	-	-	-
3	-	-	-	-	-	-	-	-
4	-	-	-	-	-	-	-	-
5	-	-	-	-	-	-	-	-
6	-	-	-	-	-	-	-	-
7	-	-	-	-	-	-	-	-
8	-	-	-	-	-	-	-	-
9	-	-	-	-	-	-	-	-
10	-	-	-	-	-	-	-	-

Titular & Co-Titular

Holder information

Dirección residencial

Información de contacto

Co-Holder Information

Plan & Beneficiarios

Planes de Cobertura

AMERICA PLAN

SERENITY PLAN

SERENITY PLUS PLAN

Lista de Beneficiarios

1

2

3

4

5

6

7

8

9

10

Mascotas

Número de mascotas

1

2

3

4

Pago

Forma de Pago

Selección de Plan

Payment Shares

Instrucciones para pagos por ZELLE.

Preguntas Médicas

Revisión Final

DATOS DEL TITULAR

DATOS DEL CO-TITULAR

PLAN & BENEFICIARIOS

RIDERS / ADD-ONS

MASCOTAS

PREGUNTAS MÉDICAS Y OBSERVACIONES

DETALLES DE PAGO

INFORMACIÓN DEL AGENTE

#	NOMBRE COMPLETO	FECHA DE NACIMIENTO	EDAD	PARENTESCO	CIUDAD/ESTADO	NACIONALIDAD	TELÉFONO	EMAIL
1	-	-	-	-	-	-	-	-
2	-	-	-	-	-	-	-	-
3	-	-	-	-	-	-	-	-
4	-	-	-	-	-	-	-	-
5	-	-	-	-	-	-	-	-
6	-	-	-	-	-	-	-	-
7	-	-	-	-	-	-	-	-
8	-	-	-	-	-	-	-	-
9	-	-	-	-	-	-	-	-
10	-	-	-	-	-	-	-	-