Quotations

  Please fill the following form with up to date data about your staff, being accurate and precise in

  providing accurate data will help us to issue a suitable offer

only an authorized person ( HR manager or other staff personnel who is authorized to contact a

  health care company ) ,may fill this form & submit it

  Company name:
  Company address:
  Tel.:
  Fax:
  Email:
  Website:
  Owner:
  Capital:

  Nature of activity:


Authorized person
 
  Name:
  Post:
  Tel.:
  Mobile:
  Email:
  Suitable time for contacting:
  Total No. of employees:
  No. of male staff:
  No. of female staff:
  Age group:
  No. of foreigners:
  What is your company's health   care system now? Gov.health insurance  Insurance company  Health care company  Non
  Insurance or health care   companies who covered your company over the past three   years:
  No. of open heart surgeries over the past three years:
  No. of cancer cases over the past three years:
  No. of coronary catheterizations in the past three years:
  No of chronic cases among your staff:
  No. of labors in the past year:
  No. of mass ( group) accidents in the past three years ( state details):


What are the criteria of the health care system you prefer?
  category

A

B

C

D
  Annual ceiling

  Hospital accommodation
  ( single \ double rooms)

  Drugs % sharing

  Intensive care
Sub ceiling\ person\ year

  Out patient   services
Sub ceiling\ person\ year

  Eye glasses
Ratio of total no. (or no. of cases) to be covered

Sub ceiling\ person\ year

  Dental treatment
Ratio of total no. (or no. of cases) to be covered

Sub ceiling\ person\ year

  Dental prosthesis
Ratio of total no.(or no. of cases) to be covered

Sub ceiling\ person\ year

  Maternity& labors
Ratio of total no.(or no. of cases) to be covered

(normal labor)
Sub ceiling\ person\ year

(caesarean labor)
Sub ceiling\ person\ year

  Chronic cases
Ratio of total no.(or no. of cases) to be covered

Sub ceiling\ person\ year

  Major cases:
1)open heart
2) therapeutic  cardiac catheters
3)cancer
4)Brain tumors
Ratio of total no.(or no. of cases) to be covered

Sub ceiling\ person\ year

 Others:
 1- 		Ratio of total no.(or no. of cases) to be covered

Sub ceiling\ person\ year

 2- Ratio of total no.(or no. of cases) to be covered

Sub ceiling\ person\ year

 3- Ratio of total no.(or no. of cases) to be covered

Sub ceiling\ person\ year