Individual/Family Plans

 
Main Applicant
Surname Given Name
Date of Birth Gender
,19 Male  Female
Nationality Email Address

Spouse/Partner  

Surname

Given Name

Date of Birth Occupation
,19
Nationality Email Address
Dependant(s)/Child(ren)  
1. Name Date of Birth
,19
2. Name Date of Birth
,19
3. Name Date of Birth
,19
Employer's Name and Address  
Company Name
Address 1
Address 2
City
State/Province/Prefecture/Region
Postal Code
Country
Telephone Ext.
Fax
Current Residential Address:  
Address 1
Address 2
City
State/Province/Prefecture/Region
Postal Code
Country
Please rate the following in terms of importance to you and our family:
Chronic Conditions
Routine checkups, drugs prescribed for condition management, hospital accommodation, nursing, surgery and palliative treatment for chronic conditions.
Maternity Coverage
Pre and post natal checkups and delivery costs (subject to a 6-12 month waiting period, dependent on the policy chosen).
Routine Dental Treatment
Examinations, tooth cleaning, normal compound fillings, porcelain crowns and extractions.
Cost of Deductible 
The costs of some policies can be affected by the cost of the
deductible.
Evacuation/Repatriation
Evacuation or repatriation to the country of your choice.
Elective Treatment in the USA
Provision for elective treatment in the United States.
In-Patient Only
Benefits restricted to costs incurred as an in-patient or day-patient plus evacuation. Out-patient treatment limited to that provided immediately following discharge.
Major Restorative Dental Work
Removal of impacted, buried or unerupted teeth, removal of roots, removal of solid odontomes, apicetomy, bridge work, crowns, root canal treatment, dentures.
Extended Home Nursing
Benefit period extended in respect of Home Nursing.
   
Most health  policies include an accidental death benefit.
Are you interested in additional life coverage?		 YES NO