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					                              Suite 300, 999 - 8th Street SW, Calgary AB, CANADA T2R 1N7
                                        Tel: (403) 232-8545 Fax: (403) 265-9425
                          email: sales@americas.msh-intl.com www.msh-intl.com/americas


GROUP QUOTE

Please note that this form is not an actual application. It is an information form that will
help us to provide the best possible quote on the coverage you require. All information that
you submit to MSH International is strictly confidential and will only be used to generate a
quote for your specific purposes. Please be patient as it may take a few minutes to complete
the form.

* These boxes must be filled out to complete the quotation.

* Full name of contact

* Email address

  Fax

  Phone

* Name of company

  Street address

  City

  State/Province

  Country

  Postal/Zip Code

* Description of company activities


  Employees’ usual daily activities




* Insurance required from (date):
                                                                                    to:



* Are employees insured under a                         YES         NO
  government sponsored health program?

  If YES, please indicate the country and
  state/province under whose jurisdiction
  the program falls
         Designing and managing international healthcare benefit solutions for you, whenever, wherever.

                                                      1 of 3
                              Suite 300, 999 - 8th Street SW, Calgary AB, CANADA T2R 1N7
                                        Tel: (403) 232-8545 Fax: (403) 265-9425
                          email: sales@americas.msh-intl.com www.msh-intl.com/americas


Please fill out the following table for each employee to be covered.

 Employee name   Gender    Date of birth      Home          Host      Occupation    Annual    Number of    Dependents’
                  (M/F)    (mm/yy/dd)        country      country/                 income/    dependents    country of
                                           under whose   country of                currency                 residence
                                           passport you assignment/
                                              travel       travel




        Designing and managing international healthcare benefit solutions for you, whenever, wherever.

                                                       2 of 3
                             Suite 300, 999 - 8th Street SW, Calgary AB, CANADA T2R 1N7
                                       Tel: (403) 232-8545 Fax: (403) 265-9425
                         email: sales@americas.msh-intl.com www.msh-intl.com/americas


Insurance required: please check off at least one of the following types of coverage.

   √                TYPE OF COVERAGE                                              AMOUNT REQUIRED
        Major medical                                                          (no amount to be entered)
        Major medical & Vision Care                                            (no amount to be entered)
        Emergency medical evacuation                                           (no amount to be entered)
        Life (enter amount and currency)
        Spousal life (enter amount and currency)
        Accidental death & dismemberment (enter amount
         and currency)
        Spousal accidental death & dismemberment (enter
         amount and currency)
        Weekly indemnity:                                                      Weekly benefit
          due to accident  due to sickness    both                           maximum of:

         Elimination Period:
          1 day for accident or sickness
          1 day for accident – 7 days for sickness

         Benefit Period:  30 days         90 days        120 days

        Long term disability:                                                  Monthly benefit
          due to accident  due to sickness                   both            maximum of:

         Elimination Period:  30 days           90 days         120 days

        Dental (no amount to be entered)

Please note that special contingency is available. Contact our office for further information.

* Please indicate the desired currency of              Canadian               US
  coverage

Disclaimer: All quotes are subject to change depending on factors such as the applicability
of any medical surcharges, the change in security status of a country to which people are
traveling, length of time between quote and actual application for insurance, etc. MSH
International does not guarantee the quoted rate as being the actual cost of coverage, but
rather proposes a reasonable approximation of the actual cost of coverage.

Thank you for taking the time to fill out this form.




        Designing and managing international healthcare benefit solutions for you, whenever, wherever.

                                                     3 of 3

				
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