INTERNATIONAL HEALTH COVERAGE

Part 1 (of 2)	Good Neighbor Insurance
690 E. Warner Rd. Suite 117, Gilbert, AZ 85296
Tel: 480-813-9100 / Fax 480-813-9930
E-MAIL: jeff@gninsurance.com
Download PDF	WEBSITE: www.gninsurance.com

REQUEST FOR GROUP QUOTE/PROPOSAL

FOR OVERSEAS MEDICAL INSURANCE

Please Print or Type All Sections

Organization Name		Contact Person
Street Address
City		State
Postal Code		Country
Phone Number		E-mail
Nature of Business
Desired Effective Date

BENEFIT PLANS DESIRED

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 [ ]

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.

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

3. Are any employees or dependents presently hospitalized, confined at home or treatment facility, disabled or incapacitated? [ ]Yes [ ] No

4. Are any employees not actively at work performing his/her normal duties due to illness or injury? [ ]Yes [ ] No

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

No international medical insurance is in effect unless the Insurance Company notifies you in writing. Final rates and coverage will be based on actual enrollment, including evidence of insurability, if applicable.


Applicant Signature:	Date

Agent Signature:	Date

Need Help? Call 480/813-9100; Fax 480/813-9930; Email: info@gninsurance.com

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INTERNATIONAL HEALTH COVERAGE

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