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	M  F	M  F	M  F	M  F	M  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 Has this person ever had life insurance or medical insurance refused, postponed, declined, withdrawn, rated, restricted or had special terms imposed?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.