|
|
|
|
Country:* |
|
State/Province:* |
|
|
|
*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 yes, how many? |
|
If any employees/dependents reside in the US, is any located in Florida? |
|
Does applicant currently have group medical insurance? |
|
Upload Limit : 2 MB (For all 3 files).
|
Allowed file extensions : PDF/JPEG/JPG/PNG/DOC/DOCX/XLS/XLSX.
|
|
Has another insurance company refused to quote on this group? |
|
Are any employees or dependents presently on COBRA? |
|
|
|
REQUESTED PLAN OF BENEFITS |
|