Part 1 (of 2) |
Good
Neighbor Insurance |
690 E. Warner Rd. Suite 117, Gilbert, AZ 85296 |
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Tel:
480-813-9100 / Fax 480-813-9930 |
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E-MAIL:
jeff@gninsurance.com |
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WEBSITE:
www.gninsurance.com |
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| REQUEST FOR GROUP QUOTE/PROPOSAL | ||||||||||||||||||||||||||||
| FOR OVERSEAS MEDICAL INSURANCE | ||||||||||||||||||||||||||||
Please Print or Type All Sections
BENEFIT PLANS DESIRED |
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| Deductible: |
[ ] |
$250 |
[ ] |
$500 |
[ ] |
$1000 |
[ ] |
$2500 |
[ ] |
$5000 |
| Lifetime Maximum |
[ ] |
$1,000,00 |
[ ] |
$5,000,000 | ||||||
| Life Insurance: |
[ ] |
$10,000 |
[ ] |
$25,000 | ||||||
[ ] |
$50,000 |
[ ] |
Other | |||||||
| Waiting Period |
[ ] |
30 days |
[ ] |
60 days |
| New Employees |
[ ] |
90 days |
[ ] |
Other |
| Are any employees presently on COBRA? |
[ ] |
Yes |
[ ] |
No |
| If YES, please provide the following information. (Attach additional sheets if necessary.) | ||||
| Employee | Date of Departure | ||
| Employee | Date of Departure | ||
| Employee | Date of Departure | ||
| Employee | Date of Departure |
| Has another insurance carrier refused your group international | |||||
| medical insurance coverage? | [
] |
Yes |
[ ] |
No | |
| Total number of employees: [___ ] |
| Total number of eligible employees: [___ ] |
| (including US-based & intl. employees) (intl. employees only) |
| How many employees have been employed less than six months? [___ ] |
| Do you expect the number of employees to vary more than 10% during the next 12 months? [ ___] |
| If YES, please explain |
| What is the employee and/or self-employed filing status with the IRS? |
| (Check all boxes that apply) c W-2 [ ] c 1099 [ ] c No Compensation [ ] |
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Does your group presently have international health insurance: ----- [ ] Yes [ ] No |
| If YES, please attach the following: |
| 1. Copy of present policy and/or booklet describing benefits. |
| 2. Copy of most recent billing statement from present carrier. |
| 3. Copy of most recent 3 years claims experience. |
| (In most instances, this can be obtained from your present or past carrier(s)) |
| Please answer the following questions to the best of your knowledge. If you answer YES to any of these questions, please provide details in the space provided below. |
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1. Has any employee or dependent suffered from a condition which resulted in a claim of $2500 or more during the last 3 years? [ ]Yes [ ] No |
| 2. Are any employees or dependents currently pregnant? [ ]Yes [ ] No |
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3. Are any employees or dependents presently hospitalized, confined at home or treatment facility, disabled or incapacitated? [ ]Yes [ ] No |
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4. Are any employees not actively at work performing his/her normal duties due to illness or injury? [ ]Yes [ ] No |
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5. Are you aware of any circumstances, chronic or continuing medical, mental or nervous conditions which can be expected to produce ongoing claims? [ ]Yes [ ] No |
| Additional Comments: (Attach additional sheets if necessary.) |
Part II
EMPLOYEE CENSUS: List each eligible employee, spouse, and dependent
child. Initial quote will be based on this census. Final rates will be determined
based on actual enrollment.
(Attach additional sheets if necessary.)
| Name of Employee | Sex | Status* | Date of Birth | Date of Hire | Country of Citizenship | Country of Residence |
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Need Help? Call 480/813-9100; Fax 480/813-9930; Email: info@gninsurance.com |