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1-800-423-8496 | 3195 Linwood Road, Suite 201, Cincinnati, Ohio 45208, United States | 513-533-1500 | Fax: 513-533-1055
Group Quote Request Form
Please fill out the following form, and Global Underwriters will generate a quote for your group as soon as possible.
Organization/Corporation Name:
Home Country Street Address:
City, State, Postal Code, Country:
Description of Group:
Special Activities:
Coverage Needed for Travel:
Inside the USA
Outside the USA
Coverage Dates:
From
to
To Be Determined
Maximum Medical Benefit:
$25,000
$50,000
$100,000
$250,000
Deductible:
$0 (approval required)
$25
$50
$100
$250
$500
$1000
$2500
Coinsurance:
100% to plan maximum
80/20 to plan $5,000 then 100% to plan maximum
Emergency Medical Evacuation:
None
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
$75,000
Repatriation of Remains:
None
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
Accidental Death & Dismemberment:
($10,000 minimum)
Emergency Reunion: ($10,000)
Yes
No
Pre-Existing Condition Exclusion:
6 Months
1 Year
2 Years
3 Years
Optional Riders:
Hazardous Activity
Athletic Rider
Home Country Coverage
Number of Participants:
Approximate Age of Participants:
Contact Name:
Contact Phone:
Contact Fax:
Contact EMail Address:
Confirm EMail Address:
