Online Forms

How to Renew CHUBB/BasicCare Health Insurance Plans – Renewal Instructions

India Network Printable PDF Forms

Please Complete the HIPPA Form if you wish to discuss claim status on behalf of the visitor.

Insurance Applications for Print and Faxing


Membership Forms Membership (pdf) –  Membership (doc)
Insurance Enrollment Forms:
CHUBB Plans Insurance CHUBB(pdf) –  Insurance CHUBB(doc)
AXIS Plan with pre-existing condition coverage Insurance AXIS(pdf) –  Insurance AXIS(doc)
AXIS BasicCare Plan


Insurance AXIS BasicCare (pdf) –  Insurance AXIS BasicCare (doc)
Insurance ReEnrollment Form Reenrollment (pdf)  – Reenrollment (doc)
Print the required form(s) and mail the completed documents to:
India Network Services
7065 Westpointe Blvd, Suite 209
Orlando, FL 32835-8758

Include (2) checks. One for Insurance Premium to India Network Services and one for
$10 membership fee payable to ‘India Network Foundation’ or Fax Completed Forms to 408-520-4967

Applicable only if cancellation occurs before start date of coverage. Cancellation Form (pdf)
Insured must complete the first page of claim form (according to policy number) and file with Administrative Concepts, Inc. (ACI) directly or along with provider office. A notarized affidavit duly signed by visitor to authorize US person to discuss claim status/questions with Administrative Concepts, Inc. (ACI).
Administrative Concepts, Inc. (ACI) Forms CHUBB Claim Form (pdf)
CHUBB Accidental Death Claim Form (pdf)
CHUBB Dismemberment Claim Form (pdf)
HIPPA Form (pdf)

Insurance Enrollment Essentials

No cancellation or refund is available on or after effective date of insurance.
India Network Foundation membership must be active in order to enroll. The $10 membership fee is not cancellable or refundable and is good for one yearRates based on total days times Daily Rate. Daily Rate based on monthly premium divided by 30 days.Couple rates are calculated based on the individual rate multiplied times 2 individuals.The member’s date of birth and passport are requested entries during enrollment process. Medical records are not required.Accident and Sickness coverage applies while visiting the U.S. Call (408)540-3600 if you have questions regarding enrollment.