Niva Bupa Health Insurance Co. ltd.
RFQ for GHI Policy
Policy Type
Company Name
Address
PAN No.
GST No.
Policy Period
Bank Name
Branch Location
Branch Code
Is there any existing Group Health Policy
Was there any Group Health Policy in last 3 years
Total Number of Employess to be covered
Total Number of lives including dependents to be covered
Are all employees being covered
Family Definition required in policy
Sum Insured
Sum Insured Basis
Room Rent (Normal) required
Room Rent (ICU) required
Pre & Post Hospitalization Expenses
Pre Existing Diseases waiting period
Initial waiting period (30 days)
Maternity benefit required
Maternity benefit (normal)
Maternity benefit (Caesarian)
Maternity waiting period (9 months)
Pre & Post Natal Expenses
Ambulance Charges
Ayush Cover
Domiciliary Cover
Health Check-up
OPD Cover
Corporate Floater
Disease wise Sub-Limit / Capping
Co-Payment
Day Care Treatment
External congenital disease cover (only in life threatening situation)
Any other cover not specified in list given above
* If it is declared by client that there is no existing group health policy or there was no group health policy in last 3
quote can be released. If the declaration is found false at later stage then the quote submitted as fresh quote w
va Bupa Health Insurance Co. ltd.
RFQ for GHI Policy
Group Health
Yes / No (If yes, then please share policy copy & latest claim MIS)
Yes / No (If yes, then please share policy copy & latest claim MIS)
Yes / No
Employee only / Employee + Spouse / Employee + Spouse + Kids /
Employee + Spouse + Kids + Parents / Parents only
As per details given in member data sheet
Floater Policy / Individual
1% / 1.5% / 2% / 3% / Single A.C. room / Actuals / Any other specific amount
1% / 1.5% / 2% / 3% / Single A.C. room / Actuals / Any other specific amount
30 / 60 days or 60 / 90 days
Yes / No
Yes / No
Yes / No
20K / 25K / 30K / 40K / 50K/ 75K / 1 Lac / Any other amount
20K / 25K / 30K / 40K / 50K/ 75K / 1 Lac / Any other amount
Yes / No
Yes / No
1K / 2K / 5K / 10K
Yes / No
Yes / No
If required -- Amount & Per family or Per member
If required -- Amount & Per family or Per member
Amount (if required)
Yes / No
Yes / No
Yes / No
ning situation)
group health policy or there was no group health policy in last 3 years then only the fresh
d false at later stage then the quote submitted as fresh quote will stand null and void.
Sr. No. Emp ID Name Relationship DOB Age Gender Sum Insured
1 EMP01 AA Self 1/1/1970 52 M 200000
2 EMP01 BB Spouse 2/2/1975 47 F
3 EMP01 CC Son 25-05-2005 16 M
4 EMP01 DD Daughter 20-08-2009 12 F
5 EMP02 XX Self 2/8/1978 43 M 500000
6 EMP03 YY Self 2/8/1972 49 F 500000
7 EMP03 ZZ Spouse 4/11/1979 42 M
8 EMP04 FF Self 2/8/1984 37 F 500000
9 EMP04 TT Spouse 2/2/1988 34 M
10 EMP04 NN Son 25-05-2010 11 M
Location Designation
Mumbai Manager
Mumbai
Mumbai
Mumbai
Pune Finance Manager
Pune AGM
Pune
Pune DGM
Pune
Pune
