If you wish to contact ChargeCare International online, please complete the information on this form – it will help us respond quickly to your enquiry:

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Country	Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic People's Republic of Korea Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands (Malvinas) Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Special Administrative Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Micronesia, Federated States of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Occupied Palestinian Territory Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Region of China Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Republic of Tanzania United States of America United States Virgin Islands Unknown Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
What type of company are you?	Please select... ---------------- Insurer / Underwriting Agent Broker / Intermediary Assistance Company Loss Adjuster / Claims Handler Cost Containment Agent
Your insured / patients, are they mostly?	Please select... ---------------- UK Citizens Other EC Citizens Outside EC English speaking Outside EC Non-English speaking Mixed
Type of Traveller involved (please select any combination)	Tour Operator Independent Traveller Expatriates
Which services interest you? (please select any combination)	In-patient bill review only Minor in-patient Out-patient bill review only Out-patient batch billing PPO / Directive Care Other
Countries of interest	Bulgaria Cyprus Dominican Republic Greece Portugal Malta Spain Tunisia Turkey Other
Case Volume - how many medical bills do you have or expect per year?	Please select... ---------------- Up to 250 251 - 500 501 - 750 751 - 1000 Over 1000 Not known   = In-patient bills Please select... ---------------- Up to 250 251 - 500 501 - 750 751 - 1000 Over 1000 Not known   = Out-patient bills
Please detail any other requirements