Intended Parents Form – Baby Shield

1Personal Information

2Details of the Surrogacy Journey

3Approvals

Personal Information

Single Parent/Couple*

Single Parent

Couple

Intended Parent #1

Name*

First Last

Email*

Phone Number*

Date of Birth*

DD slash MM slash YYYY

Gender*

Male

Female

Intended Parent #2

Name #2

First Last

Email #2

Phone Number #2

Date of Birth #2

DD slash MM slash YYYY

Gender #2

Male

Female

Address of Residence

Country*

State/Province/Region

City*

Address 1*

Address 2

Zip Code*

Country (of the Surrogacy Journey)*

U.S.A.

Canada

Mexico

Argentina

Colombia

Georgia

Armenia

Cyprus

Other

Name of our Surrogate

First Last

Details of the Surrogacy Journey

Law Firm

Lawyer

Clinic

Doctor

Nurse

Surrogacy Agency

Contact Person at the Surrogacy Agency

Concierge Agency

Contact Person at the Concierge Agency

Egg Donor Agency

Country (of the Surrogacy Journey)*

State/Province/Region of the Surrogate*

Do you currently have children from a previous journey?*

Are you with the same surrogate from the first journey?

Have you had any complications in your previous birth?

Do you have twins in your family?

Is your surrogate medically cleared?

Do you have a transfer date?

Have you had genetic testing both for yourselves and your Egg Donor?

Number of Journeys Planned

One Journey

Please elaborate on the number of journeys planned

How did you hear about us?*

Approvals

Contact a representative of Baby Shield as soon as the surrogate is approved in order to receive guidance.

The insurance costs are individual and could change in accordance with the age, gender and medical condition of the insureds.

Signatures and Approvals*

We hereby confirm and declare that we contacted TERA (Baby-Shield), at our initiative, on our accord and without any prior contact (on the agent’s part).*

Approve information transfer*

We hereby approve to transfer of the information that we provided in our request to receive services to any third party required in order to prove the services at our request.*

Registration Fees*

The registration fees are for consulting, registration, guidance, and briefing and are not related to the purchase or non-purchase of future insurance policies*

Registration process is not registration*

We recognize that this registration process and/or provision of the services by TERA (Baby-Shield) does not constitute any registration, acceptance, or underwriting process for the purpose of issuing an insurance policy by TERA (Baby-Shield) or any other third party and that any such process will be performed by solely the relevant underwriting and sales entities of the insurance companies.*

one surrogacy process*

The registration process is limited to one surrogacy process/birth only.*

Registration Fee*

The registration fee that is paid for the above registration services is final. For the sake of clarity, there is no refund of the registration costs if the intended parents decide not to purchase any insurance policies.*

Read and approved*

I have read and I approve the Regulations and the Customer Service Charter*