Vessel & Contact Information

Tell us about the vessel and the primary contact for this quote.

Vessel Details
Primary Contact
Mailing Address
Crew Numbers

Plan Preferences

Select the plan type, deductible, coverage area, and optional benefits.

Plan Type *
Standard
Core plan
Gold
Enhanced coverage
Platinum
Comprehensive coverage
Deductible *
Coverage Area *
Life Insurance Benefit
2–10 lives: $10,000 minimum required. Maximum guaranteed issue: $100,000.
Optional Benefits
Dental Benefit

General Questions

Please answer all questions. If YES, provide details in the field below.

1.Are any employees or dependents currently residing in the U.S. or Canada?
If yes, please provide details in the crew census section.
2.Do you expect the number of employees to vary in the next 12 months?
3.Does the company currently have or offer medical insurance?
If yes, provide name of carrier, current and renewal rates, schedule of benefits, and claims experience.
4.Has another insurance company refused to quote, terminated, or declined to offer coverage to the organisation or its participants?
5.Are any employees or dependents presently covered under COBRA or other continuation plans?

Health Questions

Answer YES or NO to each question. If YES, please provide details. Attach additional pages if needed.

1.Has any employee or dependent suffered from an injury, illness, or other medical/health condition that resulted in total claims, expenses, or costs of $2,500 or more during the last three years?
2.Are any employees or dependents currently hospitalised, confined at home or a treatment facility, disabled, or incapacitated?
3.Are any employees or dependents currently pregnant?
4.Are any employees or dependents not able to work or perform activities of daily living due to illness, injury, or other medical/health condition?
5.Are you aware of any circumstances, chronic, congenital, terminal, pre-existing, or continuing medical, mental, or nervous conditions which can be expected to produce ongoing claims, expenses, or costs for any employees or dependents?

Crew Census

Enter each crew member applying for coverage. Add rows as needed.

Note: This census is for groups of fewer than 100 employees. Enter one row per crew member. Annual Salary is only required if life insurance coverage based on a multiple of salary is requested.
Gender Employee Name Class Coverage Date of Birth Hire Date Occupation Annual Salary Deps. US/Can Nationality
Class: Category with common characteristics e.g. Management, Non-Management, Hourly, Salary, Exempt, Non-Exempt, Sales
Coverage: E = Employee only  |  ES = Employee + Spouse  |  EC = Employee + Child(ren)  |  EF = Employee + Family  |  D = Dependent(s) Only
Annual Salary: Required only if life insurance benefit is based on a multiple of salary  |  Deps. US/Can: Number of dependents residing in the U.S. or Canada

Review & Submit

Please review your information before submitting. Use the Back button to make corrections.

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Quote Request Submitted!

Thank you — your group medical insurance quote request has been received. Your HAML advisor will review the information and be in contact shortly.

Questions? Call +1 828-818-4265 or email connect@haml.insure