Online Forms for Insurance Enrollment | India Network Health Insurance

Secure Server Online Forms for Visitors Insurance

India Network Printable PDF Forms

Insurance Applications for Print and Faxing

Membership Forms

Membership (pdf) -  Membership (doc)

Insurance Enrollment Forms:


Insurance CHUBB(pdf) -  Insurance CHUBB(doc)

AXIS SelectCare with pre-existing condition coverage

Insurance AXIS(pdf) -  Insurance AXIS(doc)

AXIS SelectCare


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)

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

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 year

Rates 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 US.

Call (408)540-3600 if you have questions regarding enrollment.