IMMI Group RFP Form Page 1 of 3
PART 2. REQUESTED PLAN BENEFITS
Deductible: q $100 q $150 q $250 q $500 q $750 q $1,000 q Other ________________
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
Life Insurance Benet: ** q $10,000 q $25,000 q other ($100,000 maximum) ________________
2-10 lives, $10,000 minimum required. Maximum available guaranteed issue is $100,000.
Dental Benet: q Yes q No
International Marine Medical Insurance is a fully insured group benet plan. The medical portion of the benet plan is underwritten by Crum & Forster SPC, a member of the Crum & Forster
Group of Companies and is available to members of the Fairmont Specialty Trust, LTD, c/o ITA Global Trust LTD, Camana Bay, Grand Cayman.
**The Life portion of the benet plan is underwritten by International Medical Insurance Group via Alstead Re, a segregated cell company distributed, managed and administered, as agent
for IMIG, by International Medical Group®, Inc. (IMG®).
International Marine Medical Insurance
SM
(IMMI)
Request for Proposal
Vessel Name: Vessel Country of Registry:
Person Contact:
Telephone: Fax: Email:
Mailing Address: City:
State/Country: Country of residence: Postal/Zip Code:
Requested Eective Date:
__/__/__
(MM/DD/YYYY)
Total Number of Crew: Total Number of Crew Applying:
Please estimate the number of months this vessel will spend outside of U.S. waters in the next 12 months:
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 oer medical insurance? If yes, please provide name of carrier,
current and renewal rates, schedule of benets, and claims experience.
q Yes q No
Has another insurance company refused to quote, terminated, or declined to oer 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?
q Yes q No
PART 1.
PART 3. Please answer the following questions. If your answer to any question is yes, please give details in the space provided.
Attached additional pages as necessary.
1. Has any employee or dependent suered 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, conned 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
IMMI Group RFP Form Page 2 of 3
PART 4. Census Summary (required for groups of 100 lives or more)
AGE
MALE FEMALE
Employee
Employee+
Spouse
Employee+
Child(ren)
Employee+
Family
Employee
Employee+
Spouse
Employee+
Child(ren)
Employee+
Family
19-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+
CENSUS LISTING (For groups of less than 100 employees)
Gender
Employee
Name
Class***
Coverage
Needed*
(DOB) Date of
Birth
(MM/DD/YYYY)
Occupation
Annual
Salary**
# of
Dependents
Residing in
U.S. or Canada
Nationality
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
*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
***Dened as a category of employees with easily distinguishable and identiable common characteristics (i.e. management, non-management, hourly, salary, exempt, non-exempt, or sales)
IMMI Group RFP Form Page 3 of 3
PART 5. CERTIFICATION
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 certies 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 oered 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 benets are payable.
Authorized Representative Contact: Title:
Producer Name: Agency Name:
Are You the Producer of Record?
q Yes q No
Producer Signature:
Date: __/__/__ (MM/DD/YYYY)
IMG Producer Number (if contracted with IMG): Email:
Telephone: Fax:
0121
CM00501227A201222