CHAMPION  INSURANCE  ADVANTAGE, LTD.
Phone: 1-800-643-4675... 9-5 Eastern Time (M-F)           Fax: 1-410-836-7441... anytime

EST: 1994 - Now our 9th year of providing specialized travel health insurance services on the Web.
                                                                                                             "...nobody does it better"
 

1.  For International Visitors to the United States:   2.  For Travel to countries other than the United States :

As one of the original participants in The BBB Reliability Program, we are proud to make it known that we adhere to the ethical guidelines promoted by the Better Business Bureau. If you click on the logo at the left, it will take you to the Better Business Bureau's main site, where you can inspect their file on Champion Insurance. (Don't forget to come back!)

Information Request Form (this is NOT an application for insurance):
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Use this form (please complete ALL the blanks) to request rates via this Web page. All information requested is needed to provide a reply. We guarantee the information provided here will be kept confidential and will NOT be sold/given to any other entity or used for any other purpose.

NAME... first-middle-last.. your FULL name:

E-MAIL ADDRESS... essential:

GENDER: Male Female       DATE OF BIRTH: mm/dd/yy

CITIZEN OF:                        
TRAVEL   DESTINATION:

DATE YOU WANT COVERAGE TO BEGIN: mm/dd/yy

DATE YOU WANT COVERAGE TO END:     mm/dd/yy

RESIDENT MAILING ADDRESS... where you live

TYPE OF COVERAGE REQUESTED
(select the coverage you desire): SELECT FROM THE LIST BELOW: Visitors to the USA - up to 6 months (NO hazardous activity) Visitors to the USA - up to 6 months (include hazardous activity) Visitors to the USA - more than 6 months (NO hazardous activity) Visitors to the USA - more than 6 months (include hazardous activity) Travel outside the USA - up to 6 months (NO hazardous activity) Travel outside the USA - up to 6 months (include hazardous activity) Travel outside the USA - more than 6 months (NO hazardous activity) Travel outside the USA - more than 6 months (include hazardous activity) EVACUATION/REPATRIATION coverage only (6 or 12 months) TRIP CANCELLATION/CURTAILMENT coverage

SPACE FOR BRIEF REMARKS: (tell us any particulars that might be relevant)

               

(You should receive an automatic acknowledgement that we have received your form or E-mail. This automatic response is only sent the first time you contact us)

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Send E-Mail to: Travel@champion-ins.com