First Name

Last Name

Email

Phone

Relationship to person(s) requiring assistance

GlobalAssist Membership No.

(if an existing GlobalAssist™ member)

First Name

Last Name

Date of birth

Phone

Email

Number of Persons Requiring Assistance:*

Country of Residence

Additional Information

e.g. Overview of nature of incident / Injuries / Existing Health Conditions / Additional persons requiring assistance

Current Location

City

State/Province

Zip/Postal

Country

GPS/Location Coordinates:

Share your location with what3words:

Additional Information

e.g. Location / Landmarks / Specific Instructions / Nature of Emergency / Injuries Sustained / Existing Medical Conditions

Please submit any photographs that would assist the GlobalAssist™ deployment team:

Maximum file size: 5MB

e.g. Images of injuries / Location / Landmark

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