Corporate Health Insurance

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Company Name

RC Number

Contact person name

Designation

Telephone

Email

Office Address

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Industry/Nature of Business

Number of Emloyees to Cover

Categories of Staff to be Covered

Preferred Coverage Plan

Preferred Network Coverage

NationwideSelected CitiesCompany Clinic Integration

Budget Range Per Employee

Are you currently insured?

YesNo

If insured, Current Provider

What works/doesn’t?

0 /

Reason for switching

CostClaims issuesPoor serviceMore coverageOther

Include Wellness Programs?

YesNo

Need Telemedicine Access?

YesNo

Interested in Health Seminars or Fitness Activities?

YesNo

Declaration & Consent

I confirm that the information provided is accurate and consent to being contacted

GRS Insurance Brokers Limited

Call Us: 0803-028-2913, 0803-571-6364, 0703-407-6611