Group medical insurance

Source Id:
bai

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

Formerly BuyAmericanInsurance.com

Instructions:

Complete the following information about your group, then click on the SUBMIT button to e-mail your request. A GroupSales/Underwriting Representative will contact you if any clarification is required, and will respond with a written custom quotation. Thank you for your consideration.

Fields with * are required fields.

Name of organization^*
Nature of organization^*
Address of organization^*
Contact person^*
Phone Number^*
Fax Number
E-mail Address^*
Number of participants annually^*
Duration of trip(s)^*
Age range of participants^*
Any participants over age 65?	Yes No
	If yes, how many?
Origination country(ies)^*
Destination country(ies)^*
Activity or purpose of trip^*
What type of visas are participants using?^*
Previous insurance?	Yes No
If Yes, we'll require a claims history report for the last three (3) years. You may fax this report to our Group Sales/Underwriting Representative at (972) 767-4470 or if a word processor file, attach with an e-mail to us at

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