GEO
SM
Group (The Global Employer’s Option
SM
)
Request for Proposal
PART 1.
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
PART 2. REQUESTED PLAN BENEFITS
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 ___________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________
GEO
SM
Group RFP Page 1 of 2 0317
