| Group/Organization Name: |
|
Contact Person: | |
| Telephone No.: | ()
|
Fax No.: | ()
|
| Email Address: | |
| Nature of Industry: | |
| Address: | |
| City: | |
| State: | |
| Zip Code: | |
| Country: | |
| Fully Insured: | |
Administrative Services: | |
| Requested Effective Date: (mm/dd/yyyy) | |
| YES | NO |
Is the company/Organization a subsidiary or division of a US or Canadian Company? |
| |
Are any of the employees/dependants currently residing in the US or Canada? |
| |
| How Many? |
(if yes please provide a separate census) |
|
Is the Group/Organization currently insured? |
| |
| (If Yes, please provide with name of carrier, current and renewal rates, schedule of benefits and claims experience.) |
|
Has any other company refused to quote on this group? |
| |
Are there any employees currently on COBRA? |
| |
(If Yes please provide a separate census)
| |
| OPTIONS |
| DEDUCTABLE | LIFE INSURANCE |
| $100 |
$10,000 |
| $250 |
$25,000 |
| $500 |
$50,000 |
| $1,000 |
| $2,500 |
| $5,000 |
Please answer the following questions, if you answer YES to any
question please provide details in the space provided. Attach additional pages as necessary.
|
| YES | NO |
Has any employee or dependant suffered from an injury, illness or other medical/health
condition that resulted in total claims US$2,500 during the last three years? |
|
|
Are any employees or dependants currently hospitalized, confined at home or treatment facility,
disabled or incapacitated? |
|
|
Are any employees or dependants currently pregnant? |
|
|
Are any employees or dependants not actively at work performing his/her normal duties due
to an illness, injury or other medical/health condition? |
|
|
Are you aware of any circumstances, chronic or continuing, medical, mental or nervous
conditions which can be expected to produce ongoing claims for any employees or dependants? |
|
|