Caution: This is Demo Site
THE CONTOUR GROUP MEDICAL PLAN
REQUEST FOR PROPOSAL
 
Group/Organization Name:* Contact Person:*
Telephone:* Fax
Email* Nature of Industry:*
Street Address:* Postal Code:*
Country:* State/Province:*
City:* Requested Effective Date:*
(MM/DD/YYYY)
*Total number of international assignees (expatriates, third country nationals, key local nationals)
Of the international assignee population, total number of U.S citizens
Is the company/organization a subsidiary or division of a U.S. or Canadian corporation?
  
Are any employees/dependents currently residing in the U.S. or Canada?
  
If any employees/dependents reside in the US, is any located in Florida?
  
Does applicant currently have group medical insurance?
  
Has another insurance company refused to quote on this group?
  
Are any employees or dependents presently on COBRA?
  
 
REQUESTED PLAN OF BENEFITS
Deductible Max. Deductible
$250
$500
$1000
$2500
$5000
$10500
$20000
2 per family
3 per family
Lifetime Maximum
$1000000
$2000000
$5000000
Coverage in the US: Include Exclude