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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.
Max: $1,000, Deductible: $100, Preventive - 100%, Basic - 80%, Major - 50%, Orthodontia- None
Max: $1,000, Deductible: $50, Preventive - 100%, Basic - 80%, Major - 50%, Orthodontia - 50%
Max: $1,500, Deductible: $0, Preventive - 100%, Basic - 80%, Major - 50%, Orthodontia - 50%
( Describe in comments section what coverages you would like)
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
$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
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
Covered up to $150 every 24 months for routine eye exam. Covered up to $100 every 24 months for corrective lenses, contacts or frames.
Will coverage be voluntary (all eligible employees will have a choice)?
If yes, please explain:
If yes, please describe the reason for refusal:
If yes, please provide the names of employees and Date/Nature of the Event in the comments section.
- 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.
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