Good Neighbor Insurance
Omega

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GNI Omega Sign Up (v11) - 8 August 2024 - Fluent Form GNI Omega Sign Up (Same as Ninja Forms)

Insured's Details

First Name (Must match passport name):

Last Name (Must match passport name):

Known As:

Date of Birth:

Main Insured Sex:

Time planned to be in the USA during the policy

Height:

ft/in

Height (cm):

Height (ft):

Height (in):

Weight:

st & lb

Weight (kg):

Weight (st):

Weight (lb):

Family Members (ONLY family members that will be on this policy).

Spouse's First Name (Must match passport name):

Spouse's Last Name (Must match passport name):

Spouse's Date of Birth:

Spouse Time planned to be in the USA during the policy

Spouse's Sex:

Spouse's Height (cm):

Spouse's Height (ft):

Spouse's Height (in):

Spouse's Weight (kg):

Spouse's Weight (st):

Spouse's Weight (lb):

1st Child's First Name (Must match passport name)：

1st Child's Last Name (Must match passport name)：

1st Child's Date of Birth:

1st Child's Time planned to be in the USA during the policy

1st Child's Sex:

1st Child's Height (cm):

1st Child's Height (ft):

1st Child's Height (in):

1st Child's Weight (kg):

1st Child's Weight (st):

1st Child's Weight (lb):

2nd Child's First Name (Must match passport name):

2nd Child's Last Name (Must match passport name):

2nd Child's Date of Birth:

2nd Child's Time planned to be in the USA during the policy

2nd Child's Sex:

2nd Child's Height (cm):

2nd Child's Height (ft):

2nd Child's Height (in):

2nd Child's Weight (kg):

2nd Child's Weight (st):

2nd Child's Weight (lb):

3rd Child's First Name (Must match passport name):

3rd Child's Last Name (Must match passport name):

3rd Child's Date of Birth:

3rd Child's Time planned to be in the USA during the policy

3rd Child's Sex:

3rd Child's Height (cm):

3rd Child's Height (ft):

3rd Child's Height (in):

3rd Child's Weight (kg):

3rd Child's Weight (st):

3rd Child's Weight (lb):

4th Child's First Name (Must match passport name):

4th Child's Last Name (Must match passport name):

4th Child's Date of Birth:

4th Child's Time planned to be in the USA during the policy

4th Child's Sex:

4th Child's Height (cm):

4th Child's Height (ft):

4th Child's Height (in):

4th Child's Weight (kg):

4th Child's Weight (st):

4th Child's Weight (lb):

5th Child's First Name (Must match passport name):

5th Child's Last Name (Must match passport name):

5th Child's Date of Birth:

5th Child's Time planned to be in the USA during the policy

5th Child's Sex:

5th Child's Height (cm):

5th Child's Height (ft):

5th Child's Height (in):

5th Child's Weight (kg):

5th Child's Weight (st):

5th Child's Weight (lb):

Email Address (In order to ensure your email is reachable, kindly check that you receive a notification email shortly after submission of this form)

Email Address:

Please Repeat:

Mobile phone number (Please provide the best mobile phone number to reach you)

Primary Mobile Number:

Alternative Phone Number:

Country of Nationality

Home Address Line 1:

Home Address Line 2:

Home Address Line 3:

Home State/Province:

Home Post Code:

Home Country:

Country of Destination

Overseas Address Line 1:

Overseas Address Line 2:

Overseas Address Line 3:

Overseas State/Province:

Post Code:

Overseas Country:

Church or Mission

Mission's Name:

Mission's Email Address:

Communication Preferences *

If you are in a country where language relating to Christianity or missions could compromise your ministry, we are able to modify our communication methods and language to remove all references to anything that may be sensitive. Note: Sensitive communications will also remove references to Talent Trust, and may mean that you will not receive all of our communications.

Communication Preferences

I would like you to modify how you communicate with me

I would like standard communications

Emergency Contact

Emergency Full Name:

Emergency Phone:

Emergency Email:

Emergency Skype:

Referred By

Referred by:

Program Start

Start Date:

Please choose a Deductible:

Additional Options (Some options have a waiting period. Please refer to the Options Page for details)

All prices are quoted in US$ per year.

Additional Chronic Conditions Cover:

Dental:

Travel Cover:

Travel costs of insured members to be with a close relative who is at peril of death or who has died.

Personal Accident:

Non Emergency Travel:

Vision Care:

Crisis Assistance Program (CAP):

Payment Details

Payment Period:

Annual

Monthly (4.2% interest applies)

How would you like to pay?

Credit Card

Bank Transfer

Pay By Organization

How would you like to pay?

Credit Card

Pay By Organization

Credit Card Details

When your policy is set up, we will email you the credit card payment link.

Bank Transfer Details

Bank Account Name:	CITIBANK
Account Holder Name:	AWP HEALTH & LIFE SA-DUBLIN BRANCH
Account Number:	9889671
IBAN Number:	IE40CITI99005109889671
SWIFT Code:	CITIIE2X
Bank Address:	North Wall Quay Dublin 1
Bank Contact Number:
Account Currency:	USD
Account Holder's Corresponding Address:	15 Joyce Way Parkwest Business Campus Dublin 12 Ireland

Organization Details

Name of the organization

Contact Person

Organization Email

Medical Questionnaire

Note: All the following medical questions are * required

a) Have you, or anyone included in this enrollment, been admitted to hospital or other similar establishment in the last five years?

b) Have you, or anyone included in this enrollment, been prescribed with a course of any drugs or medication, or treatments for a period in excess of seven days in the last two years?

c) Have you, or anyone included in this enrollment, any known or foreseeable need to consult with a medical practitioner or any other health care professional and/or to be required to be prescribed any drugs or medication and/or to be admitted to a hospital or other similar establishment?

d) Are you, or anyone included in this enrollment, suffering from any disability, abnormality, recurrent illness, major illness or injury, not already noted above?

Important: Where you have indicated 'Yes', please use this space below to provide any additional information:

How did you hear about us?

By clicking the 'Submit' button below, you are declaring that you have read, understood, and agree to the following 5 points:

I declare that I have read, understood, and agree to the terms of the Table of Benefits and Benefits Guide.
I declare that all the information supplied for all persons on this enrollment form is accurate and complete.
I understand that no cover is provided for professional sporting activities.
I understand that I may not complete this enrollment until all material facts* connected with this enrollment have been declared in full, without misstatement or misrepresentation, and have been accepted by us in writing. I understand that failure to do so will result in cover being void from inception.
I understand that pre-existing conditions are not covered. (A pre-existing condition is any disease, illness or injury, secondary or associated complaint for which you have sought or received advice, treatment, therapy, or been submitted to a special diet - whether or not the condition has been diagnosed).

* A material fact is any information that may affect our assessment or acceptance of your enrollment for insurance. If you are unsure as to whether any piece of information is a material fact, it should be declared.

To continue, please click here so we can send your policy and other relevant info like discounts and benefits. Your info is never shared outside Talent Trust, and you can opt out at any time. *

I/We agree that Third Parties can share all relevant claims information with my personal information with Talent Trust for the purposes of tracking and processing my claims. *

NEED ASSISTANCE?

If you require assistance,
please email our support team at:

Email: info@talent-trust.com
Skype: ttc.insurance
Phone, WhatsApp: +60 (11) 1051 2677
Working hours:
Monday to Friday 10am – 6pm, GMT +8

Or enter your Email/WhatsApp and we'll get back to you:

If you have questions, please email us, and we will get back to you as soon as we can.

info@talent-trust.com

Cookie	Duration	Description
_ga	2 years	The _ga cookie, installed by Google Analytics, calculates visitor, session and campaign data and also keeps track of site usage for the site's analytics report. The cookie stores information anonymously and assigns a randomly generated number to recognize unique visitors.
_gat_UA-4028953-1	1 minute	A variation of the _gat cookie set by Google Analytics and Google Tag Manager to allow website owners to track visitor behaviour and measure site performance. The pattern element in the name contains the unique identity number of the account or website it relates to.
_gid	1 day	Installed by Google Analytics, _gid cookie stores information on how visitors use a website, while also creating an analytics report of the website's performance. Some of the data that are collected include the number of visitors, their source, and the pages they visit anonymously.
_hjAbsoluteSessionInProgress	30 minutes	Hotjar sets this cookie to detect the first pageview session of a user. This is a True/False flag set by the cookie.
_hjFirstSeen	30 minutes	Hotjar sets this cookie to identify a new user’s first session. It stores a true/false value, indicating whether it was the first time Hotjar saw this user.
_hjid	1 year	This is a Hotjar cookie that is set when the customer first lands on a page using the Hotjar script.
_hjIncludedInPageviewSample	2 minutes	Hotjar sets this cookie to know whether a user is included in the data sampling defined by the site's pageview limit.
_hjTLDTest	session	To determine the most generic cookie path that has to be used instead of the page hostname, Hotjar sets the _hjTLDTest cookie to store different URL substring alternatives until it fails.
CONSENT	2 years	YouTube sets this cookie via embedded youtube-videos and registers anonymous statistical data.

Good Neighbor Insurance Omega