Special Medical Plans Group Medical Plans Non-Medical Plans

Health and Medical Insurance Plans (Request for Family 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 $

Group discount
Can you put together a group of at least five adults (including the adults in your own plan)?
  No   5-10 Adults   10-20 adults   20+ Adults
 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
 

 

 About the people to be insured
Insured #1 Insured #2 Insured #3 Insured #4 Insured #5
Relationship to you.. (son, daughter, spouse, etc.) Yourself        
Date of birth
(DD/MM/YYYY)
         
Sex F F F F F
Height          
Weight          
Country of Citizenship          
Country of Current Residence          
 

 

 Medical information  (Y=yes, N=no)
"YES answer will require details below"
Person to be insured #1 #2 #3 #4 #5
1. Does this person engage in any hazardous work, pursuits or sports?   Y
  N
  Y
  N
  Y
  N
  Y
  N
  Y
  N
2. In the last five years, has this person consulted a doctor, specialist, or been admitted to a hospital or similar institution?   Y
  N
  Y
  N
  Y
  N
  Y
  N
  Y
  N
3. In the last five years, has this person taken or been prescribed any treatments, drugs or medications?   Y
  N
  Y
  N
  Y
  N
  Y
  N
  Y
  N
4. Does this person have any chronic or long-term medical condition or any other known disability, abnormality, illness or injury?   Y
  N
  Y
  N
  Y
  N
  Y
  N
  Y
  N
5. Has this person ever had life insurance or medical insurance refused, postponed, declined, withdrawn, rated, restricted or had special terms imposed?   Y
  N
  Y
  N
  Y
  N
  Y
  N
  Y
  N
6. Is this person currently covered by medical insurance?   Y
  N
  Y
  N
  Y
  N
  Y
  N
  Y
  N
7. Does this person smoke?   Y
  N
  Y
  N
  Y
  N
  Y
  N
  Y
  N
 

If you answered yes to any of the above questions, please indicate the question number, the person 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:
 

Thank you for completing this form
Please press "submit button" when you have finished.

  

Quotations will be indicative based on the information that you have provided in this form. Final firm quotations will be provided upon completion of the appropriate application form for the plan selected. Most plan companies offer a limited review and inspection period. During this time you may return your plan documents for a full refund, if you are not entirely satisfied.


   
 
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.