N.b5z.net
Global Benefits
James D. Smith
VP, International Sales
7150 Winton Drive, Suite 300
Indianapolis, Indiana 46268 USA
U.S. Phone: 317.735.4077 888.258.6820 ext. 177
U.S. Fax: 866.484.4710
Abroad Phone: +01 317 735 4077
Abroad Fax : +01 317 328 4640
Email: info@
INTERNATIONAL GROUP MEDICAL INSURANCE - REQUEST FOR PROPOSAL
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|Group/Organization Name: |
|Contact Person: |
|Telephone: Fax: E-mail |
|Nature of Industry: |
|Address: |
|City: State/Province: Country: Postal Code: |
|Requested Effective Date: |
|Total number of international assignees (expatriates, third country nationals, key local nationals): |
|Of the international assignee population, total number of U.S. citizens |
|Is the company/organization a subsidiary or division of a U.S. or Canadian corporation? Yes No |
|Are any employees/dependents currently residing in the U.S. or Canada? Yes No If yes, how many? |
|Does applicant currently have group medical insurance? Yes No |
|(If yes, please provide name of carrier, current and renewal rates, schedule of benefits, and claims experience.) |
|Has another insurance company refused to quote on this group? Yes No |
|Are any employees or dependents presently on COBRA? Yes No (If yes, please indicate those employees on census) |
|REQUESTED PLAN OF BENEFITS |
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|Deductible Coverage in the USA Life Insurance Other coverage’s |
|$0 Include $10,000 DBA (Defense Base Act) |
|$100 Exclude $25,000 Workers compensation |
|$250 $50,000 Liability |
|$500 Lifetime Maximum 1 X’s Salary to a Maximum of $ Business travel |
|$1,000 $1,000,000 2 X’s Salary to a Maximum of $ War & Terrorism |
|$2,500 $5,000,000 Other$ Kidnap & Ransom |
|$5,000 $ Emergency Evacuation |
|$10,000 Disability Insurance |
|$ Long term Short term PTD |
|Please answer the following questions. If your answer to any question is yes, please give details in the space provided. Attach additional pages as necessary. |
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|1. Has any employee or dependent suffered from an injury, illness or other medical/health condition that resulted in total claims of US$5,000 or more during the last|
|three years? No Yes Details: |
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|2. Are any employees or dependents currently hospitalized, confined at home or a treatment facility, disabled or incapacitated? |
|No Yes Details: |
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|3. Are any employees or dependents currently pregnant? No Yes Details: |
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|4. Are any employees or dependents not actively at work performing his/her normal duties due to illness, injury or other medical/health condition? No Yes |
|Details: |
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|5. Are you aware of any circumstances, chronic or continuing medical, mental or nervous conditions which can be expected to produce ongoing claims for any employees |
|or dependents? No Yes Details: |
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|AGE |MALE |FEMALE |
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|Gender |Name (optional) |Coverage needed* |Age or |Nationality |Country of Residence|Annual Salary |
| |(indicate if COBRA employee) | |Date of Birth | |or Assignment |(required for disability|
| | | | | | |and/or salary-based life|
| | | | | | |insurance |
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|Global Benefits is an independent Managing General Agent representing many insurance carriers globally. The undersigned representative for the within named Group |
|hereby certifies, represents and warrants that the information provided on this Request for Proposal, including any attachments, is true, accurate and complete in |
|all respects and I acknowledge that such information is intended to provide Global Benefits and its insurance carriers with information necessary to evaluate this |
|Group and provide the Group with premium and coverage indications. Final rates and coverage will be based on the actual enrollment, including evidence of |
|insurability, if applicable. No insurance shall be effective unless and until the Group is notified in writing by Global Benefits and/or the insurance carrier. |
|Thank you for allowing Global Benefits to serve you. |
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|Group Contact Name: |
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|Title: |
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|Date: |
© 2011 Global Benefits All rights reserved.
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