Inbound USA Insurance - Sample Application
Following is the sample application for Inbound USA visitors medical
insurance that will help you complete it online yourself so that you
can make an instant purchase. Please note that we have tried our best
to answer the questions in a generic manner to cover as many
applicants as possible. Please use this only as a guideline. It is
possible that your specific situation may be different than what is
described here. In case you have a question or doubt, please contact
us and we will be glad to help you fill the form. However, under no
circumstances, will we be responsible for any damages or adverse
effects arising from utilizing this sample application.
The online application should be used only if you are paying by credit card (American Express, Discover/Novus, Mastercard or Visa). If you are paying by check or money order, you can not use the online application, but will have to complete a paper application (can be downloaded from this web site). Please do not take the screen shots of an online application to use it as a paper application.
Inbound USA online application consists of 5 screens.
The online application should be used only if you are paying by credit card (American Express, Discover/Novus, Mastercard or Visa). If you are paying by check or money order, you can not use the online application, but will have to complete a paper application (can be downloaded from this web site). Please do not take the screen shots of an online application to use it as a paper application.
Inbound USA online application consists of 5 screens.
Screen 1 of 5
1. For 26% extra premium, you can get the coverage up to
$5,000 ($3,000 for 70+) if the person gets admitted into the hospital
due to a heart attack or stroke that may be due to pre-existing
conditions.
2. Date when you would like to start the coverage. Date should be entered in MM/DD/YYYY format. Coverage starts at 12:01 AM Eastern Time USA. The earliest you can start coverage from is the next day. You can not start coverage from today's date or any date in past.
If you are starting your journey from India in the early morning, in that case, it still may be the previous day according to Eastern Time USA. If you would like to get covered during travel time also, you should put one day earlier in the coverage start date. In that case, you will also have to put the arrival date in question 7 one day earlier otherwise the system will not let you proceed.
3. The date you would like to end the coverage. Please note that Inbound USA has to be purchased for at least 5 days. If you are purchasing for 3 months currently, you have to pay for 3 months right now. (You can't say you would like to purchase for 3 months, but pay for it month by month. Buying and paying is one and same thing.) Every time you renew, the insurance company will charge a $5 administrative fee. In order to avoid that, you can purchase it for the entire duration of stay. If your relative is turning 70 (or 50 or 60) midway during the stay in the U.S., you should purchase for the entire duration in the beginning itself, otherwise you will be charged the rates according to age 70 (or 50 or 60) if you renew it after turning 70 (or 50 or 60).
4. Date when you have arrived in the U.S. or will be arriving in the U.S. You can purchase this insurance any time before arriving in the U.S. or within one year of arrival in the U.S. Date should be entered in MM/DD/YYYY format. If you have entered the U.S. multiple times, you should put the date you last entered the U.S.
5. No. of people you would like to insure. You can either do a separate application for each person or a combined application. Except in the case of minor dependent children, there is no difference in the total premium, and either way, the deductible and the policy maximum are per person. If you do a separate application, you will have more flexibility in the terms of renewal or cancellation. Please read more about it in the FAQ on this web site.
If any of the persons is 70 years of age or above, you will have to do a separate application for such person.
Select 'Selected' if you would like such additional coverage. Otherwise, select 'Declined'.
6. Age of primary applicant, as of coverage start date. If you are purchasing insurance for both your parents, select your father's age. If you are purchasing only for one person, write his/her age.
7. Select whether the dependent is spouse or other dependent such as child.
8. Age of spouse of primary applicant, as of coverage start date. If you are purchasing insurance for both your parents, select your mother's age. If you are purchasing insurance only for 1 person, do not select anything in this field. Otherwise the generated quotes will include insurance for this person. For persons aged 70 years and above, you have to complete a separate application because of the reduction in benefits and increase in premiums.
If you have selected more than 2 applicants in question #1, you you will have to additionally select the age of each dependent minor child here.
9. Click this button to get the quotes displayed on the next page.
10 and 11. Currently not used.
2. Date when you would like to start the coverage. Date should be entered in MM/DD/YYYY format. Coverage starts at 12:01 AM Eastern Time USA. The earliest you can start coverage from is the next day. You can not start coverage from today's date or any date in past.
If you are starting your journey from India in the early morning, in that case, it still may be the previous day according to Eastern Time USA. If you would like to get covered during travel time also, you should put one day earlier in the coverage start date. In that case, you will also have to put the arrival date in question 7 one day earlier otherwise the system will not let you proceed.
3. The date you would like to end the coverage. Please note that Inbound USA has to be purchased for at least 5 days. If you are purchasing for 3 months currently, you have to pay for 3 months right now. (You can't say you would like to purchase for 3 months, but pay for it month by month. Buying and paying is one and same thing.) Every time you renew, the insurance company will charge a $5 administrative fee. In order to avoid that, you can purchase it for the entire duration of stay. If your relative is turning 70 (or 50 or 60) midway during the stay in the U.S., you should purchase for the entire duration in the beginning itself, otherwise you will be charged the rates according to age 70 (or 50 or 60) if you renew it after turning 70 (or 50 or 60).
4. Date when you have arrived in the U.S. or will be arriving in the U.S. You can purchase this insurance any time before arriving in the U.S. or within one year of arrival in the U.S. Date should be entered in MM/DD/YYYY format. If you have entered the U.S. multiple times, you should put the date you last entered the U.S.
5. No. of people you would like to insure. You can either do a separate application for each person or a combined application. Except in the case of minor dependent children, there is no difference in the total premium, and either way, the deductible and the policy maximum are per person. If you do a separate application, you will have more flexibility in the terms of renewal or cancellation. Please read more about it in the FAQ on this web site.
If any of the persons is 70 years of age or above, you will have to do a separate application for such person.
Select 'Selected' if you would like such additional coverage. Otherwise, select 'Declined'.
6. Age of primary applicant, as of coverage start date. If you are purchasing insurance for both your parents, select your father's age. If you are purchasing only for one person, write his/her age.
7. Select whether the dependent is spouse or other dependent such as child.
8. Age of spouse of primary applicant, as of coverage start date. If you are purchasing insurance for both your parents, select your mother's age. If you are purchasing insurance only for 1 person, do not select anything in this field. Otherwise the generated quotes will include insurance for this person. For persons aged 70 years and above, you have to complete a separate application because of the reduction in benefits and increase in premiums.
If you have selected more than 2 applicants in question #1, you you will have to additionally select the age of each dependent minor child here.
9. Click this button to get the quotes displayed on the next page.
10 and 11. Currently not used.
Screen 2 of 6
12. Overall policy maximum you would like to purchase. You
can choose from $50,000, $75,000, $100,000 or $130,000 per incident
for age 69 and below. For age 70 and above, you can choose either
$50,000 or $70,000 maximum. Please note that this is a scheduled
benefit plan and does not cover everything 100% up to the policy
maximum. Please look at the brochure for more details.
13. Displays the prices for various deductibles.
Deductible per injury/sickness. Every time you get sick or injured, you will have to pay this amount first before the insurance company starts paying anything at all. For a given injury/sickness, no matter the number of times you visit a doctor, get medicine, get other procedures done such as lab, x-ray etc, you will have to pay the deductible only once per injury/sickness. For ages up to 69, it can be either $0, $50 or $100. For ages 70 and above, it can be either $100 or $200.
Premiums are in U.S. dollars that you will have to pay right now by credit/debit card. If not paying by credit/debit card, you will have to do a paper application, which is downloadable from this web site.
13. Displays the prices for various deductibles.
Deductible per injury/sickness. Every time you get sick or injured, you will have to pay this amount first before the insurance company starts paying anything at all. For a given injury/sickness, no matter the number of times you visit a doctor, get medicine, get other procedures done such as lab, x-ray etc, you will have to pay the deductible only once per injury/sickness. For ages up to 69, it can be either $0, $50 or $100. For ages 70 and above, it can be either $100 or $200.
Premiums are in U.S. dollars that you will have to pay right now by credit/debit card. If not paying by credit/debit card, you will have to do a paper application, which is downloadable from this web site.
Screen 3 of 6
14. Primary applicant's first name, as it appears in the
passport. This name is also called 'Given Name' in some cultures. If
there is any middle name or middle initial you would like to enter,
you should enter it in this field as well. If you are applying on
behalf of your parents, you should write your father's first name
here.
15. Primary applicant's last name, as it appears in the passport. This name is also called 'Surname' in some cultures. If you are applying on behalf of your parents, you should write your father's last name here.
16. Primary applicant's date of birth. Please note that the date of birth format is MM/DD/YYYY (U.S. format) where the month is first and the day is in the middle. Be careful of the correct format in case you are directly looking at the passport for date of birth, as the format in countries like India is DD/MM/YYYY.
17. Primary applicants spouse's first name, as it appears in the passport. This name is also called 'Given Name' in some cultures. If there is any middle name or middle initial you would like to enter, you should enter it in this field as well. If you are applying on behalf of your parents, you should write your mother's first name here.
18. Primary applicants spouse's last name, as it appears in the passport. This name is also called 'Surname' in some cultures. If you are applying on behalf of your parents, you should write your mother's last name here.
19. Primary applicants spouse's date of birth. Please note that the date of birth format is MM/DD/YYYY where the month is first and the day is in the middle. Be careful of the correct format in case you are directly looking at the passport for date of birth, as the format in countries like India is DD/MM/YYYY.
20. Complete name for U.S. correspondence address. It is advisable to write the name of the person here that is staying in the U.S. If you are buying insurance for your parents, write your name here.
21. Mailing address in the U.S. In case of an apartment, please make sure to write the apartment number also in the first line.
22. Email address where you would like us to send you the instant virtual id card for this purchase. This email address will NOT be used for any spamming purpose nor will it be shared with anyone. If needed, it will be used only to communicate with you regarding the purchase of this insurance.
23. Phone number. This number will NOT be used for any telemarketing purpose nor will it be shared with anyone. If needed, it will be used only to communicate with you regarding purchase of this insurance.
24. Passport number of the primary applicant. This is confusing to many people. You do NOT have to write the passport number of the AD&D beneficiary just because this field is next to the beneficiary field. However, if any applicant is 70+ and if you are completing 2 separate applications for each person, you require passport numbers of each person, as each person will be the primary applicant in each separate application.
25. Name of the country you are a citizen of. Many times, when the person was earlier staying in the country other than his/her country of citizenship, for example, an Indian citizen was earlier staying in United Arab Emirates and meanwhile his passport expired while staying there, and the Indian Embassy in the UAE issued the new passport. In this case, you still have to write 'Country Issuing Passport' as India and NOT United Arab Emirates.
26. This is the most confusing question in the entire application. In AD&D Beneficiary, AD&D means Accidental Death & Dismemberment. Dismemberment means loosing hand(s), leg(s) or eye(s). You should write the name of the beneficiary, the person that will get money, in case the insured person dies in an accident.
If you are applying for your parents, you should usually write your name. If you are applying for your in-laws, you should usually write your spouse's name. Please don't write the name that is already covered in the application. If you are applying for both parents, do not write your father's or mother's name in this field.
27. Relationship of beneficiary with the insured(s). If you are applying for your parents, and if you wrote your name in field 26, you should select relationship as 'Child'. If you are applying only for your mother, and if you wrote your father's name in field 26, you should select relationship as 'Spouse'.
28. Please select 'Yes'. Otherwise, you will not get an insurance card or any other paperwork in the mail. In any case, you will still receive the virtual ID by email.
29. Click this button to go to the next screen.
15. Primary applicant's last name, as it appears in the passport. This name is also called 'Surname' in some cultures. If you are applying on behalf of your parents, you should write your father's last name here.
16. Primary applicant's date of birth. Please note that the date of birth format is MM/DD/YYYY (U.S. format) where the month is first and the day is in the middle. Be careful of the correct format in case you are directly looking at the passport for date of birth, as the format in countries like India is DD/MM/YYYY.
17. Primary applicants spouse's first name, as it appears in the passport. This name is also called 'Given Name' in some cultures. If there is any middle name or middle initial you would like to enter, you should enter it in this field as well. If you are applying on behalf of your parents, you should write your mother's first name here.
18. Primary applicants spouse's last name, as it appears in the passport. This name is also called 'Surname' in some cultures. If you are applying on behalf of your parents, you should write your mother's last name here.
19. Primary applicants spouse's date of birth. Please note that the date of birth format is MM/DD/YYYY where the month is first and the day is in the middle. Be careful of the correct format in case you are directly looking at the passport for date of birth, as the format in countries like India is DD/MM/YYYY.
20. Complete name for U.S. correspondence address. It is advisable to write the name of the person here that is staying in the U.S. If you are buying insurance for your parents, write your name here.
21. Mailing address in the U.S. In case of an apartment, please make sure to write the apartment number also in the first line.
22. Email address where you would like us to send you the instant virtual id card for this purchase. This email address will NOT be used for any spamming purpose nor will it be shared with anyone. If needed, it will be used only to communicate with you regarding the purchase of this insurance.
23. Phone number. This number will NOT be used for any telemarketing purpose nor will it be shared with anyone. If needed, it will be used only to communicate with you regarding purchase of this insurance.
24. Passport number of the primary applicant. This is confusing to many people. You do NOT have to write the passport number of the AD&D beneficiary just because this field is next to the beneficiary field. However, if any applicant is 70+ and if you are completing 2 separate applications for each person, you require passport numbers of each person, as each person will be the primary applicant in each separate application.
25. Name of the country you are a citizen of. Many times, when the person was earlier staying in the country other than his/her country of citizenship, for example, an Indian citizen was earlier staying in United Arab Emirates and meanwhile his passport expired while staying there, and the Indian Embassy in the UAE issued the new passport. In this case, you still have to write 'Country Issuing Passport' as India and NOT United Arab Emirates.
26. This is the most confusing question in the entire application. In AD&D Beneficiary, AD&D means Accidental Death & Dismemberment. Dismemberment means loosing hand(s), leg(s) or eye(s). You should write the name of the beneficiary, the person that will get money, in case the insured person dies in an accident.
If you are applying for your parents, you should usually write your name. If you are applying for your in-laws, you should usually write your spouse's name. Please don't write the name that is already covered in the application. If you are applying for both parents, do not write your father's or mother's name in this field.
27. Relationship of beneficiary with the insured(s). If you are applying for your parents, and if you wrote your name in field 26, you should select relationship as 'Child'. If you are applying only for your mother, and if you wrote your father's name in field 26, you should select relationship as 'Spouse'.
28. Please select 'Yes'. Otherwise, you will not get an insurance card or any other paperwork in the mail. In any case, you will still receive the virtual ID by email.
29. Click this button to go to the next screen.
Screen 4 of 6
30. Choose the credit card type you would like to pay with.
31. Name as it appears on the credit card. Here you are supposed to enter your name and NOT the financial institution that issued this credit card such as DCU, Citibank etc.
32. Credit card number. Your credit card number is secure as we use world-renowned VeriSign encryption technology. You can verify that by clicking the VeriSign logo on our web site, by making sure that the URL you are on currently starts with 'https' and there is a lock icon towards the right bottom of the browser. You will only be charged for the amount that is shown on this screen and no other subsequent charges.
33. Month and year when this credit card expires. Please enter it in MM/YYYY format. If your credit card expiration also has a day in it, please ignore it.
34. Security code. Three-digit number at the back of the card near the signature in MasterCard, Visa, Discover or four-digit number just above the main number in American Express.
35. Credit card billing address. Write street address, city, state.
36. Credit card billing zip code. Self-explanatory.
37. Your day time phone number. You will be contacted only if there is any problem processing this online application.
38. Click on this checkbox to make sure that you understand the terms and conditions of this insurance.
39. Press 'Next' button to go to next screen.
You may press the 'Back' button if you would like to make any changes in the application. Please don't click the internet browser back button or else you may loose the data you have entered so far.
Press 'Re-Quote' button if you would like to get a new quote by selecting a different deductible or different policy maximum.
31. Name as it appears on the credit card. Here you are supposed to enter your name and NOT the financial institution that issued this credit card such as DCU, Citibank etc.
32. Credit card number. Your credit card number is secure as we use world-renowned VeriSign encryption technology. You can verify that by clicking the VeriSign logo on our web site, by making sure that the URL you are on currently starts with 'https' and there is a lock icon towards the right bottom of the browser. You will only be charged for the amount that is shown on this screen and no other subsequent charges.
33. Month and year when this credit card expires. Please enter it in MM/YYYY format. If your credit card expiration also has a day in it, please ignore it.
34. Security code. Three-digit number at the back of the card near the signature in MasterCard, Visa, Discover or four-digit number just above the main number in American Express.
35. Credit card billing address. Write street address, city, state.
36. Credit card billing zip code. Self-explanatory.
37. Your day time phone number. You will be contacted only if there is any problem processing this online application.
38. Click on this checkbox to make sure that you understand the terms and conditions of this insurance.
39. Press 'Next' button to go to next screen.
You may press the 'Back' button if you would like to make any changes in the application. Please don't click the internet browser back button or else you may loose the data you have entered so far.
Press 'Re-Quote' button if you would like to get a new quote by selecting a different deductible or different policy maximum.
Screen 5 of 6
Thoroughly review the information you have entered so far. This is
your last chance to make any changes before the purchase is made.
40. You may press the 'Back' button if you would like to make any changes in the application. Please don't click the internet browser back button or else you may loose the data you have entered so far.
Press the 'Re-Quote' button if you would like to get a new quote by selecting a different deductible or different policy maximum.
Otherwise, press the 'Purchase' button to proceed with purchase.
40. You may press the 'Back' button if you would like to make any changes in the application. Please don't click the internet browser back button or else you may loose the data you have entered so far.
Press the 'Re-Quote' button if you would like to get a new quote by selecting a different deductible or different policy maximum.
Otherwise, press the 'Purchase' button to proceed with purchase.
Screen 6 of 6
You are done. This is the instant confirmation for your insurance
purchase. The virtual ID card is as good as the real insurance card
that will be mailed to you by regular U.S. mail at latest by the next
business day. You may want to print this confirmation for your
records. Please note that it takes about 4-5 business days for
regular U.S. mail to deliver your mail.
The system also generates an email copy of this confirmation and sends it to the email address you specified.
URL for this page: http://www.insubuy.com/sevencorners/inbound-usa-insurance/
The system also generates an email copy of this confirmation and sends it to the email address you specified.
URL for this page: http://www.insubuy.com/sevencorners/inbound-usa-insurance/