Special Medical Plans Group Medical Plans Non-Medical Plans

Health and Medical Insurance Plans (Request for Individual Plan Quotation)
   
Name  
  Last, First, MI
Occupation  
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 $
 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
 
 About
Date of birth (DD/MM/YYYY) Weight
Sex M  F Country of Citizenship
Height Country of Current Residence
 
 Medical information  (Y=yes, N=no)
"YES answer will require details below"
1. Do you engage in any hazardous work, pursuits or sports? Y N
2. In the last five years, have you consulted a doctor, specialist, or been admitted to a hospital or similar institution? Y N
3. In the last five years, have you taken or been prescribed any treatments, drugs or medications? Y N
4. Do you have any chronic or long-term medical condition or any other known disability, abnormality, illness or injury? Y N
5. Have you ever had life insurance or medical insurance refused, postponed, declined, withdrawn, rated, restricted or had special terms imposed? Y N
6. Are you currently covered by medical insurance? Y N
7. Do you smoke? Y N
 
If you answered yes to any of the above questions, please indicate the question number and give details.
Notes

1. If the details apply to question 1, please describe the hazards.
2. For questions 2 to 5, please include; medical condition diagnosed, dates treated, where treated, prognosis, and any ongoing treatment. Also include name(s) of medication, frequency, and dosage being taken at this time.
3. For question 6, please include name of the current insurance company, and why you wish to add any additional coverage or are considering changing to another company.

Please provide any other information that may help plan underwriters better understand your medical history and current state of health. This allows them to provide their best quotations:


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OMNI Group - Centralized Liaison Office
5th Flr. Salustiana D. Ty Tower, 104 Paseo De Roxas,
Legaspi Village, Makati, Philippines 1262
Tel: (632) 810-0487   Fax: (632) 810-0761
  OMNI Capital (Far East), Limited
  4/Floor Galuxe Building
  8-10 On Lan St., Central Hong Kong
  Tel: (852) 2523-2167   Fax: (852) 2810-1957
OMNI is an active member of: American Chamber, Canadian Chamber, European Chamber, Australian-New Zealand
 Chamber, Lighthouse Club, Le Club, British Business Association.