Group Proposal Request

Group Proposal Form

Group Health Insurance Please fill out an submit completed form for proposal
Please check one of the following options	New Client Current Client
Please check one of the following options	School Company or Group
Client Name
Address
Telephone
Fax
Email
Contact Person
Occupation
Health Insurance A group may be divided into different areas of coverage. For example, half of a group may be covered under the Worldwide policy, while the other half may be covered under the International policy. List the number of people to be insured in each group according to the following categories: Single, Couple, Family
Geographic Coverage Worldwide	Single Couple Family
Geographic Coverage International Plus	Single Couple Family
Geographic Coverage International	Single Couple Family
Deductible and Co-Payments
Deductable	$0 $100 $250 $500 $1,000 $2,000 $5,000
Co-Payment	0% 10% 20% 30%
Additional Benefits
Dental	Yes No
Vision	Yes No
Life Insurance	Yes No
Life Insurance Amount
Number of Insured
Long Term Disability	Yes No
LTD Waiting Period	3 Months 6 Months 1 Year
LTD Benefit Level	60% 80%
Total Payroll ($US)
Inflation Rate	0% 3%
Names of each individual (Please give DOB, Nationality, Benefit amount and profession for all members)
Tiecare Representative (if any)
Please submit your application, and TieCare will review immediately