LinkedInThis field is for validation purposes and should be left unchanged.Applicant InfromationIntended Parent(s) Name(s):(Required)FirstLastDate of Birth (mm/dd/yyyy) Add RemoveMarital Status:(Required) Single Married Divorced Widowed Home Address:(Required) Street Address City State / Province / Region ZIP / Postal Code Phone Number:(Required)Email Address:(Required) Surrogacy DetailsWhat stage of the surrogacy process are you in?(Required) Considering Surrogacy Matching with a Surrogate Contract Signed Medical Process Started Pregnancy Confirmed Surrogacy Agency Name (if applicable):(Required)Surrogacy Agency Name (if applicable):Surrogate's Name (if Known):(Required)Surrogate's Date of Birth:(Required) MM slash DD slash YYYY Surrogate's State of Residence:(Required) State / Province / Region Will the surrogate be using her own health insurance policy?(Required) Yes No Unsure If yes, provide carrier name:(Required)Does the policy have surrogacy exclusions?(Required) Yes No Unsure Coverage NeedsWhat type of surrogacy insurance coverage do you need?(Required) Medical Insurance for the Surrogate Complication Coverage for the Surrogate Life Insurance for the Surrogate Newborn Medical Coverage Disability Insurance for the Surrogate Escrow and Legal Coverage for Surrogacy Expenses Estimated Surrogacy Budget:(Required)Do you have existing insurance policy that may cover surrogacy-related expenses?(Required) Yes No If yes, provide details:(Required)Do you need assistance finding a health insurance policy for the surrogate?(Required) Yes No Medical & Pregnancy History (For Surrogate) *You have indicated there is not currently a surrogate contract in place. This section will be skipped unless indicated otherwise. Has the surrogate had prior pregnancies?(Required) Yes No If yes, how many live births?(Required)Any history of pregnancy complications?(Required) Yes No If yes, provide details:(Required)Has the surrogate been previously approved for a surrogacy journey?(Required) Yes No Does the surrogate have any pre-existing medical conditions?(Required) Yes No If yes, list conditions:(Required)Legal & Construction InformationDo you have a surrogacy contract in place?(Required) Yes No If yes, is it attorney-reviewed?(Required) Yes No Please name the reviewing attorney:(Required)Are there legal considerations regarding parental rights in your state?(Required) Yes No Unsure If yes, please describe considerations:(Required)Do you need assistance with legal coverage for surrogacy agreements?(Required) Yes No If yes, please describe assistance needs:(Required)Additional InformationUse the space below to provide any other relevant information or special considerations that may affect your insurance policy. Δ
