Crew C Visa Health Insurance Application

Crew Information

Crew Position/Rank *

Vessel/Aircraft Type *

Company/Employer Name *

Contract Duration (months) *

Port/Airport of Entry *

Expected Arrival Date *

Previous Crew Visa History

First time applicant 1-3 previous visas 4+ previous visas

Personal Information

Full Name (as per seaman's book/crew ID) *

Seaman's Book/Crew ID Number *

Passport Number *

Passport Expiry Date *

Nationality *

Date of Birth *

Gender *

Male Female Other

Email Address *

Emergency Contact

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Emergency Contact Email

Medical Declaration

Date of Last Maritime/Aviation Medical Examination *

Do you have a valid Maritime/Aviation Fitness Certificate? *

Yes, I have a valid certificate No, I need to obtain one

Vaccination Records

Please indicate which of the following vaccinations you have received:

Medical Conditions

Please indicate if you have any of the following conditions:

Current Medications (if any)

Physical Fitness Declaration *

I am in excellent physical condition and can perform all duties I am in good physical condition with minor limitations I have some physical limitations but can perform essential duties

Insurance Package Selection

Please select the insurance package that best suits your needs. All packages provide coverage while you are working under your Crew C Visa.

Basic Crew Coverage

$500

Emergency medical coverage up to $10,000
Basic repatriation coverage
24/7 emergency assistance hotline
No pre-existing condition coverage

Recommended for short-term contracts in low-risk environments

Standard Crew Coverage

$1500

Emergency medical coverage up to $50,000
Enhanced repatriation coverage
Emergency medical evacuation
Limited pre-existing condition coverage

Recommended for medium-term contracts with standard duties

Extended Crew Coverage

$5000

Emergency medical coverage up to $100,000
Full repatriation coverage
Emergency medical evacuation & transport
Standard pre-existing condition coverage
Personal liability coverage

Recommended for long-term contracts or high-risk environments

Comprehensive Crew Coverage

$10,000

Emergency medical coverage up to $1,000,000
Premium repatriation & family transport
Worldwide emergency medical evacuation
Full pre-existing condition coverage
Extended personal liability coverage
Loss of income protection

Recommended for senior crew with high-value contracts

Coverage Period

Coverage Start Date *

Coverage Duration *

Include multiple entry coverage (additional 15% premium)

Premium Calculator

Base Premium: $0.00

Multiple Entry Option: $0.00

Duration Adjustment: $0.00

Total Premium: $0.00

Application Summary

Please review your information before submission

Ensure all details are correct. Once submitted, you will receive a confirmation email with your policy details and payment instructions.

Crew Information

Position/Rank:
Vessel/Aircraft Type:
Company/Employer:
Contract Duration:
Port/Airport of Entry:
Expected Arrival:

Personal Information

Full Name:
Crew ID Number:
Passport Number:
Nationality:
Date of Birth:
Gender:

Selected Insurance Package

Coverage Period:

Multiple Entry:

Total Premium:

Payment Method

Credit Card

PayPal

Bank Transfer

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Crew C Visa Health Insurance

Health Insurance Application for Crew C Visa

Crew Information

Personal Information

Emergency Contact

Medical Declaration

Vaccination Records

Medical Conditions

Insurance Package Selection

Basic Crew Coverage

Standard Crew Coverage

Extended Crew Coverage

Comprehensive Crew Coverage

Coverage Period

Premium Calculator

Application Summary

Please review your information before submission

Crew Information

Personal Information

Selected Insurance Package

Payment Method

Application Submitted!