MP+International
Request for Proposal
PART 1.
Participating Organization Name:

Authorized Representative Contact:

Telephone:

Fax:

Email:

Street Address:

City:

State/Province:

Country:

Postal/Zip Code:Total Number of Eligible
International Employees:

Total Number of U.S. Citizens
Included in the International
Employee Count:

Nature of Business:

Requested Effective Date:(Day, Mo., Yr.)

Type of Work Employees Perform:

Total Number ofInternational Employees:

Total Number ofLocal Nationals Applying:

Is the company/organization a subsidiary or division of a U.S. or Canadian corporation? If Yes,U.S. or Canadian?

qYes

q

No

Are any employees/dependents currently residing in the U.S. or Canada? If Yes, please provide details incensus section.

q

Yes

q

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

q

Yes

q

No

Have any covered employees and appointed representatives been employed for less than 6 months?
If yes, how many? _______

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 claims experience.

qYes

q

No

Has another insurance company refused to quote, terminated, or declined to offer coverage to theorganization 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.

qYes

q

No

If local nationals are applying for coverage, will the employees be travelling outside of their country ofresidence? If Yes, how often? For how long?

qYesq

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

Coverage Plan:

q Standard

Coverage Area (Choose One):q $750 q $1,000 q $2,500 q $5,000 q $10,000 q Other: $__________

q AlternativeMaximum Deductible: q 2 per Familyq 3 per Familyq 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 Platinum USA Benefit Rider
q Other:________________________ q Daily Hospital Indemnity
q Creditable Coverage Offset
q Guarantee Issue for New Employees q AD&D
q Dental 1 q Dental 2 q Dental 3
Lifetime Maximum:

q $1,000,000

q $5,000,000

q $8,000,000

q Other: $_______________

Life Insurance Benefit:(Optional)

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 $_________________

Implementation needs:

q Reporting _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

q Enrollment ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PART 3. REQUESTED SERVICES (ADDITONAL ASSISTANCE SERVICES UPON REQUEST)

q Medical Security Evacuation Services
MP+International RFP

q Travel Intelligence Portal				

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q Remote Mental Health Services		q Teleconsultation		

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For organizations with 2-24 employees:
PART 4. 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?

q

Yes

q

No

2.

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

q

Yes

q

No

3.

Are any employees or dependents currently pregnant?

qYes

q

No

4.

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

qYes

qNo

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?

qYes

qNo

PART 5. CENSUS LISTING (For groups of less than 100 employees)

Gender

Employee Name

Date ofBirth

Coverage
Needed**Class*

Occupation(MM/DD/YYYY)

AnnualSalary***# ofDependents
Residingin U.S. orCanadaCitizenshipCountry ofAssignment___/___/______/___/______/___/______/___/______/___/______/___/______/___/______/___/______/___/______/___/___*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)**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 salaryPART 6. 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 his or her knowledge and belief. It is understood IMG and the insurance carrier intend to rely on thisinformation 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 offered to eligible participants whoseapplications are approved in writing by IMG and following timely receipt of premium owed and 2) this document is merely an invitation toinquire, not an application, and not a description of any losses for which benefits are payable.
Authorized Representative Contact:

Title:

Producer Name: Rodrigo De Souza

Agency Name:Are You the Producer of Record? qYesqNo

Producer Signature:

Date (Day, Mo., Yr.):

IMG Producer Number (if contracted with IMG): 531050

Email: insurance@imglobal.com

Telephone: 1.866.368.3724

Fax:

Send by one of the following secure methods:
Secure Message Center: www.imglobal.com/secure-message-center
Encrypted Email: insurance@imglobal.com

MP+International RFPCM00501208A201218				

Fax: +1.317.655.4505
For other inquiries call: +1.317.655.4500

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