OmniPortal: Insured Nomads: Benefits for modern companies, remote workers and travelers

Group Health Request Form

Group Health Proposal Request
View the health plan elements via this link and complete the form below. Once received, we will advance and work on it for you.

View options in this PDF, click to view

First Name*

Last Name*

Primary Email*

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:*

Number of Employees to be included for this quote:

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

What area(s) will this group need coverage?

What is the desired start date*

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

Inpatient deductible desired: (deductible/excess for inpatient services)*

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 Outpatient Copay Percentage

Please Select Your Dental/Optical Benefit

Dental/Optical A

Dental/Optical B

Please Select Your Maternity Benefit

Maternity A

Maternity B

Please upload any supporting documents here: