International group health insurance - Census form

Source Id:
bai

US/Canada: (866) INSU-BUY, International: (972) 985-4400


Formerly BuyAmericanInsurance.com

International group health insurance quote request form

Please provide us as much information as possible for the most accurate quotes and we would be glad to provide you with free and no obligation group health insurance quotes from multiple companies.
The information you provide will be kept strictly confidential and will be used for quote purposes only.

Page 1 of 3

Contact Information

Group/Organization name^*
Type/Industry of group^*
Standard Industry Code (SIC)
Contact person^*
Title

Phone 1^*
Phone 2
Fax
Best time to reach you
Email^*
Web site

Address 1^*
Address 2
City^*
State/Province^*
Postal code^*
Country^*

Medical Coverage Information

Requested effective date^*	mm/dd/yyyy
Desired plan type^*	Fully Insured Stop Loss ASO
US/Canada coverage^*	Include Exclude
Deductible^*	$100 $150 $250 $500 $1,000 $2,500 $5,000 $10,000 $20,000 $25,000 Other
Max. deductible^*	2 per family 3 per family
Inside US/Canada - Out of Network^*	60% of $5,000 80% of $5,000 90% of $5,000 Other % of $
Outside US/Canada & US In-Network^*	100% Other % of $
Requested benefit schedule^*	$1,000,000 $5,000,000 - Comprehensive $5,000,000 - Fixed Custom Plan (Provide details in the comments section) To Follow Expiring Plan (Provide policy wording describing benefits)
Prescription drug card	Yes No If yes, Plan A - $10 generic/$20 brand name Plan B - $15 generic/$30 brand name Plan C - Usual, Reasonable and Customary (Subject to Deductible and Coinsurance) Plan D - 50% of Usual, Reasonable and Customary (Subject to Deductible and Coinsurance)
Waiting period for new employees^*	0 days 30 days 60 days 90 days Other
Desired underwriting method	Individual Underwriting "12/12" Pre-Ex Clause (Pre-Existing Conditions treated in the 12 months prior to the effective date will not be paid during the first 12 months of this plan.) Full Take-Over Provision (i.e., No Loss/No Gain. For Take-Over Provision, we must receive detailed claims experience listed below in order to provide a Binding Quote.)

Life Insurance Information

Term life insurance benefit

$10,000
$25,000
$50,000
1X's Salary to a Maximum of $
2X's Salary to a Maximum of $
3X's Salary to a Maximum of $
Other
There may be a maximum available limit for guaranteed issue

Dental Plan Benefits

None
Option 1
Max: $1,000, Deductible: $100, Preventive - 100%, Basic - 80%, Major - 50%, Orthodontia- None
Option 2
Max: $1,000, Deductible: $50, Preventive - 100%, Basic - 80%, Major - 50%, Orthodontia - 50%
Option 3
Max: $1,500, Deductible: $0, Preventive - 100%, Basic - 80%, Major - 50%, Orthodontia - 50%
Other ( Describe in comments section what coverages you would like)

Additional Benefits

Preventive Package	Benefits are available after 12 months of coverage and are not subject to Deductible Employees and Dependents age 30 and above: $250 per Insured Person Per Calendar Year Female Insured Persons age 40 and over (or qualifying Woman at Risk): $100 per Insured Person per Calendar Year for a screening mammogram Dependent Children under age 19: up to 3 visits ($75 maximum per visit) for routine wellness
Emergency Assistance Package	Emergency Medical Evacuation: for Insured Persons under the age of 65 $50,000 Lifetime Maximum $100,000 Lifetime Maximum $150,000 Lifetime Maximum Emergency Reunion: $15,000 per Certificate Period Repatriation of Remains: $25,000 Maximum per Insured Person
Mental Health Disorders	$25,000 Lifetime Maximum after 12 months of continuous coverage, subject to the following sub-limits: Outpatient Treatment: 50% of a maximum charge of $100 per visit with a maximum of 52 visits per Calendar Year per Insured Person Inpatien Treatment: $10,000 per Calendar Year per Insured Person
Hospital Indemnity	$100 per day, seven day maximum (excluding hospitalization for maternity)
Vision Package	After 12 months of continuous coverage and subject to $50 Deductible. Covered up to $150 every 24 months for routine eye exam. Covered up to $100 every 24 months for corrective lenses, contacts or frames.

Group Information

Total number of employees (including US based and international employees)^*

Total number of international assignees (expatriates, third country nationals, key local nationals)^*

Of the international assignee population, total number of U.S. citizens^*

Total number of employees applying for coverage^*

Will coverage be mandatory (all eligible employees will be enrolled)? or
Will coverage be voluntary (all eligible employees will have a choice)?

Has the number of employees stated above increased or decreased by more than 10% in the past 24 months and/or will it increase or decrease by more than 10% for the requested period of coverage? Yes No
If yes, please explain:

Please define class or classes of employees to which insurance is to apply if insurance will not apply to all employees (i.e. Managers, Staff, Executives, etc.).

Is the company/organization a subsidiary or division of a US or Canadian corporation?^* Yes No

Has another insurance company refused to quote on this group?^* Yes No
If yes, please describe the reason for refusal:

Are any eligible employees presently on COBRA? Yes No
If yes, please provide the names of employees and Date/Nature of the Event in the comments section.

Does the employer group presently have domestic and/or international group medical coverage?^* Yes No

If yes, please provide the following either by email to or fax to (972) 767-4470:

Copy of policy or booklet describing benefits and/or specific plan details including deductible, lifetime maximum, etc.
Name of insurance company, current and renewal rates.
Copy of most recent billing statement.
Copy of most recent 3 years claims experience and/or 3 years of rates and benefit history.
Policy period dates for all of the above.

The above information is necessary to provide creditable quotes. Please ensure all information is provided.

Reason for changing:

Claim Experience

Please answer the following questions. If your answer to any question is yes, please give details in the space provided.

1. Has any employee or dependent suffered from an injury, illness or other medical/health condition that resulted in total claims of US $2,500 or more during the last 3 years? Yes No

2. 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 3 years? Yes No

3. Are any employees or dependents currently pregnant? Yes No

4. Are any employees or dependents currently hospitalized, confined at home or a treatment facility, disabled or incapacitated? Yes No

5. Are any employees or dependents not actively at work performing his/her normal duties due to illness, injury or other medical/health condition? Yes No

6. 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? Yes No

Claims experience comments:

Other comments:

Census Information

Census that includes the information about all eligible employees and their dependents is required. If any information is missing or incomplete, there may be a delay in processing your request. Minimum of 2 employees are required for the group quotes.

For each employee, Gender(Male/Female), Name, Status (Employee, Employee & Spouse, Employee & Children, Family), No. of Children, Birth Date (MM/DD/YYYY), Annual Salary, Nationality and the Country of Residence are required. For each dependent, Gender(Male/Female), Name, Birth Date (MM/DD/YYYY), Nationality and the Country of Residence are required.

You can either upload a spreadsheet containing all that data or you can enter all the data yourself in next 2 screens.

How would you like to submit the census data?^*

Submit spread sheet
Either email it to or fax it to (972) 767-4470.

Sample spreadsheet containing the sample census data
Template spreadsheet to use for census data. When complete, SAVE your census to a local drive. If you already have an excel spreadsheet containing the census information, you can use that as long as all the necessary data is included.

Online data entry

Home \| About Us \| Achievements \| Companies \| Disclaimer \| Plans \| Privacy Policy \| Site Map Insurance Agent Sign up
Copyright © 2002-2010 Insubuy^®, Inc. All rights reserved.