INDIA NETWORK SERVICES
INDIA NETWORK HEALTH INSURANCE ENROLLMENT FORM
Underwritten By the Insurance Company of the State of Pennsylvania, A Member
Company of American International Group, Inc. (AIG)
Complete two forms if spouse falls in different age group - 18-49, 50-69, 70-79, 80+. If both fall in one age group, you may complete one form by including one in the dependent table. PLEASE Complete the form in your Browser & fax the completed form to: 800-837-6384
General
Information of the Insured (person requiring insurance).
| Name (Last, First, MI): | ||
| Address (street): | ||
| City: | State: | Zip: |
| DOB (mm/dd/yy): | Passport #: |
| H Phone: | Work Phone: |
| E-Mail: | |
List Dependents to be insured below. Dependent coverage is available only if the Visitor is also insured.
| Last Name | First Name | Date of Birth (mm/dd/yy) |
Passport # |
Payment Instructions: Determine Premiums from the table. You may pay the premium amount by credit card Amex/Visa/MasterCard or pay by check made payable to India Network Services, in US Dollars.
Check the Coverage Requested: [ ] $50K Policy Max [ ] $100K Policy Max [ ] $150K Policy Max
Choose the Deductible : [ ] $75 [ ] $250 [ ] $500 (fixed for 70 and over aged)
PERIODS OF COVERAGE
I want renew coverage from the date ____/____/____ and continue for ____ months. I hereby authorize charge of Total Premium $ (=Premium per month X number of months + $5 Admin fee) to my
Credit Card number _______________________Exp. Date ___/___ Vcode: _______
Cardholder’s Signature _________________________ Date ___/___/___
Important: Coverage will be effective the date the correct premium is received by the Company or a representative of the Company or the effective date of the coverage period, whichever is later, unless otherwise stated in the Master Policy GLB9102820/9102821. It is the Visitor’s responsibility for timely renewal. By signing below, the Visitor acknowledges the following: (1) He/She has carefully read, understand, and agrees to the terms and conditions of the coverage, including the pre-existing condition limitations and elects to enroll as indicated on this enrollment form; (2) Rates are not prorated other than as listed on this enrollment form; (3) He/She meets the eligibility requirements for this coverage as described in the program description; (4) if it is later determined that the Visitor is not eligible, the premium will be refunded; and (5) I have read, understood and agree with the cancellation policy as outlined in the Program document on the web.
Signature of Person Completing: ___________________ Date ____/____/____
India Network Member Name/SSN & Relationship: ___________________________________
(c) India Network Services, Inc.