Insured Nomads - Insured Nomads Juvo Group Health Request Form

Thank you for your interest in Juvo Group Health Plans!
The initial quote provided is a general estimate based on the basic details submitted through this form.
For a more accurate and personalized quote, please gather the information listed below and either attach it to this form or send it to us separately via email.

View Juvo Brochure Here

Insured Nomads Juvo Group Health Request Form

Personal Information:

Primary Email*

First Name*

Last Name*

Company or Organization Name

If you are representing a company or organization, please complete this field with your company or organization's name. If you are doing business as an individual, then leave this field blank.

Linkedin url

Website*

Address Line 1*

Address Line 2

City*

State / Province

ZIP / Postal Code*

Country*

Referred by: (partner, broker, friend's name) if applicable, provide details:

Travel & Insurance Information

Number of Employees to be included for this quote:*

What is the desired start date*

Plan Selection: (select your desired annual medical maximum benefit, per person)*

Optional Benefits, mark if these should be included*

Outpatient

Maternity

Dental/Optical

No: Only present proposal with medical/health, wellbeing, safety/security

Please Select Your Optional Outpatient Module

Outpatient A

Outpatient B

Outpatient C

Please Select Your Dental/Optical Benefit

Dental/Optical A

Dental/Optical B

Please Select Your Maternity Benefit

Maternity A

Maternity B

Please Select Your Outpatient Copay Percentage

Choose Your Inpatient Deductible Amount: (deductible/excess for inpatient services)*

In what country or countries will the insured be initially or primarily residing?

What area(s) will this group need coverage?*

Share a scheduling link for a call to discuss (Calendly/Cal.com/Hubspot)

Please upload any supporting documents here:

Thank you for filling out this form. Our team will be in touch with you shortly!
In the meantime, please don't hesitate to reach out to members@insurednomads.com with any additional questions.