Group (The Global Employers Option
Request for Proposal
Participating Organization Name: Authorized Representative Contact:
Telephone: Email:
Street Address: City:
State/Province: Country: Postal/Zip Code:
Requested Effective Date:
(Day, Mo., Yr.)
Industry: Type of Work Employees Perform:
Total Number of Eligible International Employees: Total Number of U.S. Citizens
Included in Census:
Total Number of Local Nationals
Included in Census:
Is the company/organization a subsidiary or division of a U.S. or Canadian corporation? If Yes,
U.S. or Canadian?
q Yes q No
Are any employees/dependents currently residing in the U.S. or Canada? If Yes, please provide details in
census section.
q Yes q No
Do you expect the number of employees to vary in the next 12 months? If Yes, please provide details.
q Yes q No
Does the company currently have or offer medical insurance? If Yes, please provide name of carrier,
current and renewal rates, schedule of benefits, and three years of claims experience, if available.
q Yes q No
Has another insurance company refused to quote, terminated, or declined to offer coverage to the
organization or its participants? If Yes, please provide details.
q Yes q No
Are any employees or dependents presently covered under COBRA or other continuation plans? If Yes,
please indicate those individuals in the census.
q Yes q No
If local nationals are applying for coverage, will the employees be travelling outside of their country of
residence? If Yes, how often? For how long?
q Yes q No
Non-U.S. Deductible: q $0 q $100 q $250 q $500 q $750 q $1,000 q $2,500 q $5,000 q $10,000 q Other: $ __________
U.S. Deductible: q $0 q $100 q $250 q $500 q $750 q $1,000 q $2,500 q $5,000 q $10,000 q Other: $ __________
Coverage Plan: q Standard q Alternative Maximum Deductible: q 2 per Family q 3 per Family
Coverage Area (Choose One): q Worldwide q Custom – Please indicate countries covered:_________________________________________
q Worldwide Excluding* the U.S., Canada, China, Hong Kong, Japan, Macau, Singapore and Taiwan
*Except 30 days emergency/accident
Additional Benefits Upon Request: q Adventure Sports Rider q Dental q Platinum USA Benefit Rider
q Creditable Coverage Offset q Daily Hospital Indemnity q Other:_________________________
q Long-term Disability*(Please submit complete Disability Questionnaire) q Guarantee Issue for New Employees
*Disability products are administered and underwritten by Zurich American Life Insurance Company
Lifetime Maximum: q $1,000,000 q $5,000,000 q $8,000,000 q Other: $_______________
Life Insurance Benefit*: q $10,000 q $25,000 q $50,000 q 1 x Salary to maximum of $___________
q 2 x Salary to maximum of $__________ q 3 x Salary to maximum of $___________
q Other $_________________ * (2-10 lives, $10,000 minimum required). Maximum available guaranteed issue is $100,000.
Implementation needs: q Reporting ____________________________________________________________________________________
q Enrollment ___________________________________________________________________________________
Group RFP Page 1 of 2 0317
PART 3. Please answer the following questions. If your answer to any question is Yes, please give details in the space provided.
Attach additional pages as necessary.
1. Has any employee or dependent suffered from an injury, illness or other medical/health condition that
resulted in total claims, expenses, or costs of $2,500 or more during the last three years?
q Yes q No
2. Are any employees or dependents currently hospitalized, confined at home or a treatment facility, disabled
or incapacitated?
q Yes q No
3. Are any employees or dependents currently pregnant?
q Yes q No
4. Are any employees or dependents not able to work or perform activities of daily living due to illness, injury
or other medical/health condition?
q Yes q No
5. Are you aware of any circumstances, chronic, congenital, terminal, pre-existing, or continuing medical,
mental or nervous conditions which can be expected to produce ongoing claims, expenses, or costs for any
employees or dependents?
q Yes q No
PART 4. CENSUS LISTING (For groups of less than 100 employees)
Gender Employee Name Class*
Date of
Birth or
# of
in U.S. or
Country of
*Defined as a category of employees with easily distinguishable and identifiable common characteristics (i.e. management, non-management, hourly, salary, exempt, non-exempt, or sales)
**Status: Employee only (E) Employee+ Spouse (ES) Employee+ Child(ren) (EC) Employee+ Family (EF) (attach additional pages as necessary)
***Provide salary only if a proposal is desired for life insurance coverage based upon a multiple of salary
International Medical Group®, Inc., is authorized representative, and plan administrator of the insurance contract which may be issued by
the insurance carrier. IMG or the insurance carrier may ask for more information, depending on the request, responses, and information
later revealed. The undersigned plan administrator and/or authorized representative of the plan certifies all information shown on this form
is correct and complete to the best of his or her knowledge and belief. It is understood IMG and the insurance carrier intend to rely on this
information as part of the premium and coverage evaluation process. It is also understood if the information provided is not accurate, truthful,
correct, and complete, IMG and the insurance carrier reserve the right to decline coverage, terminate coverage or revise premium rates
accordingly. The plan and the undersigned acknowledge, understand, and agree 1) coverage is only offered to eligible participants whose
applications are approved in writing by IMG and following timely receipt of premium owed and 2) this document is merely an invitation to
inquire, not an application, and not a description of any losses for which benefits are payable.
Producer Name: Agency Name:
Are you the Producer of Record? q Yes q No
IMG Producer Number (if contracted with IMG): Email:
For organizations with 2-24 employees:
Group RFP Page 2 of 2 0317