IMG GEO +Plus International

Now you have a truly Global Option for your international employee benefits!

International Medical Group^SM, Inc., a worldwide leader in designing and servicing global healthcare benefits, has developed the GEO family of insurance plans, the Global Employers' Options^SM. GEO is a revolutionary program designed to meet the global healthcare needs of international assignees, and provide multinational employers with flexible options of both benefits and services.

For more information and a complete quote for your group, just fill out the form below and an HI4.com representative will contact you immediately.

REQUEST A QUOTE

Group / Organization Information
Please complete all fields marked with an askterisk (*).

Group / Organization Name*:

Contact Person*:


(First Name*)	(Last Name*)

Address*:

Address 2:

City*:

State or Province:

(* US and Canada only)

Postal Code:

Country*:

Telephone*:

Fax:

Email*:

Nature of Industry*:

Requested Effective Date*:

(MM/DD/YYYY)

Total number of non-U.S. citizens*:

Total number of U.S. citizens*:

Is the company / organization a subsidiary or division of a
U.S. or Canadian corporation?* Yes No

How many employees / dependents are currently residing
in the U.S. or Canada?*

Does the applicant currently have
group medical insurance?* Yes No

(If yes, please provide the name of carrier, current and/or renewal rates, schedule of benefits, and claims experience.)

Has another insurance company refused to
quote on this group?* Yes No

Are any employees / dependents presently
on COBRA?* Yes No