Go One Global Corporation - Visitors Insurance

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Request for Group Census
to review your Group Benefit Package

Name of Business
City	# of Full time Employees
County	# of Part time Employees
Phone #	Present Carrier
Fax #	Renewal Date
E Mail Address	Sic code
Type of business

Check the benefits that you would like us to include in your quote

Medical			Dental
Long Term Disability			Group Life Insurance
Prescription Drug Cards			Well Baby Care
Maternity Full Coverage			Workers Compensation
Full Takeover Required			Additional Life Insurance
Vision			Other
Medical Plans you would like to have: Check all that apply	HMO	PPO	POS	Indemnity	Self-Insured

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High priorities (Check appropriate boxes)
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Improve Current Benefits

Sec.125 Program/Cafeteria Plan

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This will help us focus our attention on areas that concern you:

Present concerns or dislikes
Premiums		Excellent Pleased Concerned Displeased
Benefits		Excellent Pleased Concerned Displeased
List of Providers		Excellent Pleased Concerned Displeased
Claims Service		Excellent Pleased Concerned Displeased
Agent/Broker Service		Excellent Pleased Concerned Displeased
Other:		Excellent Pleased Concerned Displeased
Other:		Excellent Pleased Concerned Displeased
Name of Current Broker

Employee Name (Optional)	Annual Salary (Optional for disability)	Age/DOB	Sex	Dependent Status	Home Zip Code	Preferable Physician of Choice(Optional)

For more than 11 employees, please contact us for complete analysis.

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G1G.com signs a product outsourcing agreement with MetGA, the wholly owned subsidiary of MetLife Corporation (July 2002) Cheapfares.com inks agreement with G1G.com to offer G1G’s travel insurance products through its web portal (Oct 2002) Go One Global Corp moves to new expanded offices for enhanced customer service and hiring additional personnel (Oct 2002) G1G sponsors the International Players’ Cricket Tour in Houston, TX Major milestone of 250 affiliate producers is reached by G1G.com (March 2002) • G1G sponsors the international players’ cricket tourney in Houston, TX (August 2002) • Go One Global Corp moves to new expanded offices for enhanced customer service and hiring additional personnel (Oct 2002) • Cheapfares.com inks agreement with G1G to offer G1G’s travel insurance products through its web portal (Oct 2002)

G1G Insurance Services/Go One Global Corp has individual designated licenses under different state jurisdictions. Go One Global Corp is a leading Insurance Corporation. Licensed to Sell Insurance in Most US States
CA License#: 0D75473
DE License#: 173718

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