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INSURANCE APPLICATIONS FOR
PRINT AND FAX TO:
407-479-3289.
1. Membership form InfMem.pdf
InfMem.doc
2. Insurance Enrollment Form InsForm.pdf
InsForm.doc
3. Insurance Renewal Form
RenewalForm.pdf
RenewalForm.doc
Instructions: Print the forms
and mail completed forms to
India Network Services
7065 Westpointe Blvd, Suite 201
Orlando, FL 32835-8758
along with checks for correct amount of premium and
membership fee ($10), payable to 'India Network Services'. or fax
completed forms to 407-479-3289
4.
Cancellation Form
(Only if cancellation occurs before start date of coverage).
5. Claim Form (in
pdf format) -
Insured must complete the first page of
claim form (according to policy number) and file with
Chartis Claims Office either directly or along with provider
office. Also, get a notarized affidavit duly signed by visitor
to authorize US person to discuss claim status/questions with
Chartis.
6.
HIPPA Form Please complete and
fax this form if you wish to discuss claim status on behalf of
the visitor.
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