Group Name
Contact Person
Group Activities
Full Address
Telephone	Fax
Email
Where / How did you learn about OMNI ?

 

How do you want to build your medical insurance plan:  Budget
You may indicate your maximum annual budget for this insurance						US $
Amount of deductible/excess acceptable
	None		Low		Medium		High
	I want fullest reimbursement of eligible claims		I'll pay the first US $500 of any claim				I'll pay the first, say, US $5,000 of any claim
Do you prefer to include coverage for the following  (each YES might increase the premium):
	Highest standard of hospital room, board and services available				Medical emergency evacuation
	Out-patient care (in addition to the standard in-patient care)				Routine pregnancy and childbirth
|Geographical coverage required
	World-wide				Western Europe (Only)
	Worldwide excluding North America and the Caribbean
	World-wide excluding North America, Caribbean, Japan and Hong Kong (SAR)
	Limited to country of residence, except when travelling
Maximum length of stay in North America or the Caribbean in any one policy year.
Payment options
How do you want to pay for your insurance? (annual premiums are lower in cost)
	Annually		Semi-annually		Quarterly		Monthly

 

Current Group Plan Particulars - (if a current group medical plan exists we will need the following items in order to provide you with our best coverage and premium rate quotations. If not provided at this time, rates will probably be conservative and definitely indicatively provided from Plan Underwriters.)

1. Full copy of existing policy - or - benefits description booklet.
2. Copy of most recent billing statement.
3. Copy of most recent 3 years claims experience summary.

Medical information  (Y=yes, N=no) "YES answer will require details below"
1. Has any employee or dependent suffered from a condition that resulted in a claim of $5,000 or more during the last 5 years?	Y N
2. Are any Group principal members or dependents currently pregnant?	Y N
3. Are any Group Principal members or dependents currently hospitalized, confined at home, disabled or incapacitated?	Y N
4. Are any Group principal members not actively at work performing normal duties due to illness or injury?	Y N
5. Are you aware of any circumstances or conditions which can be expected to produce an ongoing medical claim?	Y N

If you answered yes to any of the above questions, please indicate the question number, the person number, and give details.