Haiti

Clinical Trial Application	Haiti Clinical Trial Quote Request
Mandated Coverage	n/a
Standard Limits	n/a
Tail Coverage	n/a
Data Required to Quote	• Clinical Trial Quote Request • Protocol and Informed Consent Form in English • Local Representative details (Contact Person Name, Address, Telephone Number and E-Mail Address) and NIF (Haitian Tax ID #) • No refund for policy cancellation

Clinical Trial Application	Ecuador Clinical Trial Quote Request Ecuador Know Your Customer Form
Mandated Coverage	Yes
Standard Limits	n/a
Tail Coverage	n/a
Data Required to Quote	• Clinical Trial Quote Request • Protocol and Informed Consent Form in English • Protocol Title in Spanish • Local Legal Representative/CRO details (Contact Person Name, Telephone Number and E-mail Address) and RUC number (Ecuadorian Tax ID) • No refund for policy cancellation - CRO or Local Legal Representative must provide the completed "Know Your Customer Form"