Group Medical Travel Insurance Quote Request

Proposed Effective Date

Coverage is provided through a master policy issued to International Helpers (Guernsey) Trust. AON Services (Guernsey) Limited acts as trustee for this master policy. Enrollees become participants in master policy #PUSNA0801288. By paying the participation fee, coverage is afforded to the enrollee once confirmed by Custom Assurance Placements, Ltd. View the participation agreement (PDF Doc).

Group Medical Travel Insurance Application

Coverage is available for employer groups and can be offered on a per member per month fee basis. For an indication of terms and prices, please complete the below application.

Proposed Effective Date

Employer Group Name:

FEIN

Address:

City:

State:

Zip:

Yes No - Will you be using a travel facilitator to arrange all overseas medical travel?

Please provide the name of the facilitating organization.

Please explain:

What is the nature of the company's operations? (i.e.- description of business)

Who is the carrier for your group health insurance? If self funded, please list the administrator’s information.

Please provide the group health insurance policy or plan number and a copy of most your most recent census. If census is available electronically, provide access options.

How many covered members in your group health plan are eligible for the overseas medical option?

Is the member's overseas medical treatment mandatory or optional?
Mandatory
Optional
Incentive Driven

If incentive driven, please provide details.

Yes No - Do you want to include all international travel (business and leisure travel), not only travel for overseas medical procedures?

How many employees regularly travel overseas for business per year?

Estimated number of business travel days for all employees per year?

Please choose which Capital Sum limits you would like your group members to have.

   $50,000
   $100,000
   $150,000
   $200,000
   $250,000

*Please note: Per member per month (PMPM) participation fee will vary based on which capital sum is chosen. An increase in utilization could affect the rate with a 30 day written notice.

Provide additional details here along with any remarks or questions:

CONTACT INFORMATION

Name:

Email:

Phone:

Fax:

CUSTOM ASSURANCE PLACEMENTS, LTD. DISCLAIMERS

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORAMTION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRADULANT INSURANCE ACT WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (Not Applicable in CO, HI, NE, OH, OK, or VT; in DC, LA, ME, TN and VA Insurance benefits may also be denied).

Please note that the participation fee for this insurance will be changed on a per employee per month basis. We will charge monthly using your group billing and send an invoice to be paid.

INSURANCE IS NOT IN EFFECT UNTIL THIS APPLICATION IS RECEIVED AND CONFIRMATION IS PROVIDED.