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International Group Health Insurance - Census Form

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Thank you for your interest in international group health insurance plans.

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Whether you have a small group (5-50 participants) or large group (50+ participants) in your organization, we have group major medical insurance plans that would suit your needs and your budget. Even though we offer plans in many states across the United States, please note that not all plans are available in all states.

The information you provide is strictly confidential and will be used only for quote purposes.

Your request has been sent!

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Contact Details * Required

Organization Name is required.

Contact Person Name is required.

Phone Number is required.

Email Address is required.

Enter a valid email address.

City is required.

State/Province is required.

Country is required.

Quote Request Details

Requested Effective Date is required.

Requested Effective Date cannot be in past.

Please enter the Requested Effective Date in the specified format.

Coverage Area is required.

Total Number of Eligible International Employees is required.

Number of US Citizens is required.

Number of Non-US Citizens is required.

Industry is required.

Type Of Work Employees Perform is required.

Enter Insureds Added {{ travelersTotal }} travelers

Age Group is required.

# of Insureds is required.

# of Insureds must be a number.

Close [X]

Please check Age Group and # of Insureds.

Minimum 5 insureds required.

I, as a representative for the within named Group, hereby certify, represent and warrant that the information provided on this Request for Proposal is true, accurate and complete in all aspects and I acknowledge that such information is intended to provide Insubuy®, Inc. with information necessary to evaluate this Group and provide the Group with premium and coverage indications.

I understand that by submitting this form, I am appointing Insubuy®, Inc. as a broker of record for the above group. I can revoke the broker of record only with a 60 days prior written notice.

Upon submission of this request, I understand that more information may be required in order to get accurate quotes and I agree to coordinate in providing the necessary details promptly.

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 the insurance company.

Verification Code is required

Enter correct Verification Code.

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