Allianz health Insurance quote request form

First name *

Last name *

Email address *

Date of birth *

Nationality *

Do you also want to insure family members? If yes, please list their date of birth and nationality below.

Destination - Country of residence *

Expected duration of your stay abroad *

Area of Cover *

Worldwide excluding USA

Worldwide including USA

Africa only

Start date / date of departure *

Cover - Inpatient +

Outpatient

Dental

Maternity

Repatriation

How much deductible would you prefer for inpatient care?

How much co-payment would you prefer for outpatient care?

0% co-payment = 0% discount

10% (max. € 1.480) = 12% discount

20% (max. € 2.962) = 24% discount

30% (max € 3.705) = 35% discount

Not applicable (no outpatient cover)

Questions or Comments:

Allianz Care quote request