Policyholder Information

La Vie A l'Etranger

Coverage Period

Coverage Start Date (mm/dd/yyyy) *

Destination *

State *

Basic Information

First Name *

Last Name *

Applicant's Email *

Date of Birth (mm/dd/yyyy) *

Sex *

Male

Female

Nationality *

French Social Security Number *

Would you like to combine your CFE Coverage with your WellAway?

Yes

U.S. visa type *

This product is ACA compliant.

Once you provide WellAway with your approval letter from the CFE (Attestation d'Affiliation and Situation des Beneficiaires, if applicable), and any CFE waiting periods have been satisfied, you will receive the corresponding CFE discount on the first day of the following month.

Origin Phone *

Destination Phone *

Dependent Information

Add your spouse/domestic partner to the policy. *

Yes

Number of dependents

We keep your information safe! Do you consent with your personal data being processed as described in the Privacy Policy? Click Yes to continue.

Yes

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