Apply and Pay – Access HMO

Insured Information

First Name: *

Last name: *

Date-of-Birth: *

Mobile Number with country code: *

E-mail: *

Occupation:

Passport Number: *

Nationality - Home Country: *

Date of Departure from home country:

What is your Height (in/cm)? *

What is your Weight (lbs/kg)? *

Date of Next Return to Home Country:

Residence Address after starting date

Street & Number: *

City/Municipality: *

State/Region

ZIP/Postal Code: *

Country: *

Telephone Number:

Home Country Address or Billing Address

Street & Number: *

City/Municipality: *

State/Region

ZIP/Postal Code: *

Country: *

Telephone Number:

Spouse Information

First Name: *

Last name: *

Date-of-Birth: *

Phone Number with country code: *

E-mail: *

Nationality: *

Passport Number: *

What is your Height (in/cm)?

What is your Weight (lbs/kg)?

Expected residency and travel itinerary for the next year

Travel and Foreign Residency Dates and Destinations
Will you visit The United States, Canada, China, Hong Kong, Japan, Macau, Singapore or Taiwan during the policy period? Yes No

Do you have a U.S Green Card or U.S Visa?* Yes No

Please provide all tentative and planed travel destinations for the next 12 months with approximate departure, transit and return dates

Delivery and Payment

How would you prefer to receive your insurance documents and ID card(s)? * Via E-mail

Your Insurance documents and ID card will be send to your email address within 12 hours after we receive your payment.

Regular Mail/Post

Your Insurance documents and ID card will be send to your mailing address within 12 hours after we receive your payment.

Your Insurance documents and ID card will be waiting for you in our office within 12 hours after we receive your payment. Please contact us to schedule an appointment at your convenience.

DHL express delivery (at your expense)

Your Insurance documents and ID card will be express delivered to your mailing address via DHL within 12 hours after we receive your payment. You will be billed separately for this service at DHL’s rates.

Shall we also send your insurance documents directly to a consulate, embassy or any state office that issues visas and residency permits in order to expedite your visa delivery? Yes No

Payment methods: * Credit or Debit Card

Online Bank Transfer

Bank transfer fees are charged on your account. We will send your documents within 12 hours after payment is completed.

By appointment only. Please contact us to schedule an appointment at your convenience.

Cash at any branch of Raiffeisen Bank (using our deposit form)

Please fill out and print our deposit form to pay in person at any Raiffeisenbank Branch. We will send your documents within 12 hours after receipt of payment.

At VZP for Foreigners, we always strive to deliver the most prompt service to our customer's fullest satisfaction. However, if by any chance you receive a blank page, Don't Worry. You will receive an email with confirmation of your application submission as well as payment instructions.

Health Insurance Application Form