International Marine Medical InsuranceSM (IMMI)
Request for Proposal
1. GENERAL INFORMATION
Vessel Name:

Vessel Country of Registry:

Primary Contact:
Telephone:

Fax:

Email:

Mailing Address:

City:

State/Country:

Country of Residence:

Total Number of Crew:

Requested Effective Date:__/__/__ (MM/DD/YYYY)

Postal/Zip Code: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

q Yes

q No

q Yes

q No

q Yes

q No

q Yes

q No

Do you expect the number of employees to vary in the next 12 months? If yes, please provide details.

Does the company currently have or offer medical insurance? If yes, please provide name of carrier,current and renewal rates, schedule of benefits, and claims experience.

Has another insurance company refused to quote, terminated, or declined to offer coverage to theorganization or its participants? If yes, please provide details.

Are any employees or dependents presently covered under COBRA or other continuation plans?

2. REQUESTED PLAN BENEFITS
q International Marine Medical Insurance

q International Marine Medical Insurance GoldDeductible:

q $500q $100q $150Coverage Area (Choose One):q $250q Worldwide

q $750q $1,000

q International Marine Medical Insurance Platinum

q Other ________________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/accidentLife Insurance Benefit: **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 Benefit:

IMMI Group RFP Form

q Yes

q No

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q Optional Sports Expansion Coverage(included with IMMI Gold plan)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?

2. Are any employees or dependents currently hospitalized, confined at home or a treatment facility, disabled, orincapacitated?

q Yes

q No

q Yes

q No

q Yes

q No

q Yes

q No

q Yes

q No

3. Are any employees or dependents currently pregnant?

4. Are any employees or dependents not able to work or perform activities of daily living due to illness, injury, or othermedical/health condition?

5. Are you aware of any circumstances, chronic, congenital, terminal, pre-existing, or continuing medical, mental, ornervous conditions which can be expected to produce ongoing claims, expenses, or costs for any employees ordependents?

4. CENSUS SUMMARY (Required for groups of 100 lives or more)
MALE
AGE

Employee

Employee+
SpouseEmployee+Child(ren)

FEMALE
Employee+
FamilyEmployee

Employee+
SpouseEmployee+Child(ren)Employee+
Family

19-24
25-29
30-34
35-39
40-4445-49
50-54
55-59
60-64
65-69
70+International Marine Medical Insurance is a fully insured group benefit plan. The medical portion of the benefit 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 benefit plan is underwritten by International Medical Insurance Group via Alstead Re, a segregated cell company distributed, managed, and administered, as agentfor IMIG, by International Medical Group®, Inc. (IMG®).

IMMI Group RFP Form

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CENSUS LISTING (For groups of fewer than 100 employees) Attach additional pages as necessary.
GenderEmployee
NameClass***

Coverage
Needed*Date of Birth(MM/DD/YYYY)

Occupation

AnnualSalary**# ofDependents
Residing inU.S. or Canada

Nationality__/__/____/__/____/__/____/__/____/__/____/__/____/__/____/__/____/__/__*Status: Employee only (E)Employee+ Spouse (ES)

Employee+ Child(ren) (EC)

Employee+ Family (EF)**Provide salary only if a proposal is desired for life insurance coverage based upon a multiple of salary***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)

5. CERTIFICATIONInternational 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 hisor 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, andagree 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.
Authorized Representative Contact:

Title:

Producer Name: HIRANO - HOLCOMB INSURANCE AGENCY, LLC

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: masako@mhhinsurance.com

533361

Telephone:Fax:

For other inquiries, contact IMG by:

Secure Message Center: www.imglobal.com/secure-message-center
Fax: +1.317.655.4505

Phone: +1.317.655.4500
Email: insurance@imglobal.com

CM00501640A220228

Send by one of the following secure methods:

IMMI Group RFP Form

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