Insubuy Insurance

8 AM-9 PM CST.
Seven Days a Week

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
Phone
Phone 2
Fax
Address 1


Address 2


City
State/Province
Postal Code


Country




Medical Coverage Information
Choose the date when you would like to start your insurance mm/dd/yyyy
  Fully Insured     Stop Loss     ASO
 Include    Exclude
 $100
 $150
 $250
 $500
 $1,000
 $2,500
 $5,000
 $10,000
 $20,000
 $25,000
 Other  
 2 per family    3 per family
 60% of $5,000
 80% of $5,000
 90% of $5,000
 Other   % of $
 100%    Other % of $
 $1,000,000
 $5,000,000 - Comprehensive Comprehensive Coverage
 $5,000,000 - Fixed Fixed Coverage
 Custom Plan (Provide details in the comments section)
 To Follow Expiring Plan (Provide policy wording describing benefits)
 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)
 0 days    30 days    60 days    90 days  
 Other
 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
 $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
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 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
$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
Inpatient Treatment: $10,000 per Calendar Year per Insured Person
$100 per day, seven day maximum (excluding hospitalization for maternity)
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)?

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.).


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:


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:
  1. Copy of policy or booklet describing benefits and/or specific plan details including deductible, lifetime maximum, etc.
  2. Name of insurance company, current and renewal rates.
  3. Copy of most recent billing statement.
  4. Copy of most recent 3 years claims experience and/or 3 years of rates and benefit history.
  5. 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