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 Benet: ** 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 Benet: q Yes q No
International Marine Medical Insurance is a fully insured group benet plan. The medical portion of the benet 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 benet 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 Eective 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 oer medical insurance? If yes, please provide name of carrier,
current and renewal rates, schedule of benets, and claims experience.
q Yes q No
Has another insurance company refused to quote, terminated, or declined to oer 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 suered 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, conned 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
