TENDER SUBMISSION FORM Contract Title: Health Insurance for ...

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Primary Contact Mobile No. Direct Landline No. Quote Details. Insurance Company. Divisional Office. Divisional Officer N
TENDER SUBMISSION FORM Contract Title: Health Insurance for teachers (including retired) of St. Stanislaus High School One signed original and two copies of this form and each of the documents mentioned in it must be supplied in a sealed blank envelope.

Details of Person Quoting Tenderer Name

Allocated Service Office Address

Type of Entity (Insurance Company/Insurance Broker/Insurance Agency) License no. License effective upto Name and Designation of Primary Contact Primary Contact Email id Primary Contact Mobile No. Direct Landline No. Quote Details Insurance Company Divisional Office Divisional Officer Name Divisional Officer Contact No. of Members Covered in the quote Sum Insured Room Rent Limit for Normal Rooms (1% of Sum Insured/No Limits/Any amount?) Room Rent Limit for ICU (2% of Sum Insured/No Limits/Any amount?) (Yes/No) Complete Waiver of Pre-existing Exclusion including Internal Congenital (Yes/No) Complete Waiver of Waiting Period for Specified Ailments (Yes/No) Waiver of 30 Days Exclusion (Yes/No) Sub-limits on Surgeries (Yes/No) Any other Sub-Limits? (Yes/No) Hospitalization due to Terrorism (Yes/No)

Pre-Hospitalization (Days) Post-Hospitalization (Days) Restriction of Network Hospitals (Yes/No) Domiciliary Hospitalization Cover (Yes/No) No Co-pay (Yes/No) Name of TPA Maximum Age of Members Total Premium (Inclusive of Service Tax and all other costs)

Service Checklist Error Free Physical Cards within 30 days of policy effective (Yes/No) Single Point Dedicated Account Manager for employees/members (Yes/No) Claims Pickup in Mumbai (Yes/No) Regular updation of Claims (Yes/No) Quarterly Claims MIS (Yes/No) Maximum Committed TAT for Claims Settlement (in Working Days) Maximum Response TAT for Support Requests (in Working Hours) Escalation Email id Escalation Mobile No. Escalation Direct Landline No.

I, the undersigned, being the authorized signatory of the above tenderer hereby declare that we have examined and accept without reserve or restriction the entire contents of the tender form above. We propose to provide the services requested on the basis of our offer.

Name of Entity

Signature of Authorized Signatory with Company Stamp

Designation of Authorized Signatory