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ABOUT US
OUR PLANS
Sky Health Plan
Sun Health Plan
Star Health Plan
PROVIDERS
Freedom to Choose
Hygeia
Red Star
CONTACT US
APPLICATION FORM Part- 1 of 4
PAYMENT FORM
Annual
Semi-Annual
Quarterly (TDC)
Monthly (TDC)
Check
Credit Card
Wire Transfer
PLANS / COVERAGES
Plan Sky
Plan Sun
Plan Star
$1,000,000
2,000,000 ( Optional Sky ) DEDUCTIBLE: $
$250
$500
$1,000
$2,500
$5,000
$10,000
$20,000
1. APPLICANT INFORMATION
NAME
1
LAS NAME(S)
RELATION
SEX
M
F
DATE OF BIRTH
AGE
HEIGHT
WEIGHT
NACIONALITY
PREMIUM
► PLEASE CLICK ON THE BAR TO ADD MORE....
NAME
2
LAS NAME(S)
RELATION
SEX
M
F
DATE OF BIRTH
HEIGHT
WEIGHT
PESO
NACIONALITY
PREMIUM
NAME
3
LAS NAME(S)
RELATION
SEX
M
F
DATE OF BIRTH
HEIGHT
WEIGHT
PESO
NACIONALITY
PREMIUM
NAME
4
LAS NAME(S)
RELATION
SEX
M
F
DATE OF BIRTH
HEIGHT
WEIGHT
PESO
NACIONALITY
PREMIUM
NAME
5
LAS NAME(S)
RELATION
SEX
M
F
DATE OF BIRTH
HEIGHT
WEIGHT
PESO
NACIONALITY
PREMIUM
FILING STATUS
Married
Single
Divorced
Widowed
INCLUDE COPY OF PICTURE ID OF THE MAIN INSURED.
If spouse and/ or children are not include in the application explain why:
2.
OPTIONAL SUPPLEMENTS
Single mother maternity $300
Student in the United States $375
3. PREMIUMS
ANNUAL PREMIUM
PREMIUM FACTOR
Anual x 1
Semestral x 0.55
Trimestral x 0.28
Mensual x 0.10
ADMINISTRATIVE COST
TOTAL PREMIUM
4. PERMANENT RESIDENCE ADDRESS
Por favor provea un email valido para assistirle con la mas exacta informacion.
ADDRESS
CITY
COUNTRY
PHONE:
CELL:
EMAIL:
5.
MAILING ADDRESS
(If Other)
ADDRESS
CITY
COUNTRY
PHONE:
CELL:
EMAIL:
6. EMPLOYER'S NAME AND ADDRESS
EMPLOYER
NATURE OF BUSINESS
ADDRESS
CITY
COUNTRY
PHONE:
CELL:
EMAIL:
7.
OCUPATION AND TITLE
MAIN INSURED
TITLE
LIST SPECIFIC DUTIES
SPOUSE
TITLE
LIST SPECIFIC DUTIES
Online Application
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Pay Online
Forms / Brochures
Claim Process
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