Italian Trade Commission
Trade Promotion Section
of the Consulate General of Italy
All. B) al disciplinare di gara
OFFERTA ECONOMICA
Procedura aperta per l’affidamento dei servizi assicurativi relativi al contratto unico di assicurazione
del personale locale della rete USA in carico all’ Istituto nazionale per il Commercio Estero – Ufficio di
New York
II sottoscritto
_________________________________________________________________________________
Nato a
__________________________________________________il_______________________________
Residente a
_______________________________________________Provincia__________________________
Stato
_________________________________________________________________________________
Via/Piazza
_________________________________________________________________________________
in qualita’ di Legale rappresentante dell'Impresa
_________________________________________________________________________________
oppure quale procuratore del legale rappresentante dell'Impresa
________________________________________________________________________________
Con sede a
______________________________________________Provincia___________________________
Stato
_________________________________________________________________________________
Via/Piazza
_________________________________________________________________________________
Con codice fiscale numero
_________________________________________________________________________________
E con partita IV A numero
_________________________________________________________________________________
Telefono
Fax
_________________________________________________________________________________
OFFRE
Quale premio complessivo per le coperture assicurative delle spese mediche e dentistiche nonché
dell’assicurazione vita rischio morte e altre invalidità permanenti a favore degli impiegati locali in
servizio presso i propri uffici di Atlanta, Chicago, Los Angeles, Miami e New York, per un periodo di un
anno a decorrere dalla data di stipula del contratto,
l’importo comprensivo di eventuali imposte di US$............................................................(in cifre)
US$..........................................................................................................................................(in lettere)
Praticando un ribasso percentuale del………………sull’importo a base d’asta.
come dettagliato nella tabelle di seguito riportate:
New York Office
33 East 67th Street
New York, NY 10065-5949
T 212-980-1500 F 212-758-1050
[email protected] www.italtrade.com
ICE Istituto nazionale per il Commercio Estero
via Liszt 21, 00144 Roma, Italia
T +39 0659921 F +39 06 89280311
www.ice.gov.it
Cod. Fisc. 80069170589 Part. Iva 02120151002
1) PERSONAL AND DEPENDENT MEDICAL EXPENSE INSURANCE
Medical Coverage
In-Network Benefits
Medical Deductible
Not
Applicable
Out-of-pocket maximums (calendar Year,
does not include deductible)
Not
Applicable
Medical Maximum
$5,000,000
Out-of-Network Benefits
$250.00
individual
$750.00
$2,000.00
family
individual
$6,000.00
80%
80%
family
Life Time Maximum,
except as shown below
after deductible
after deductible
80%
after deductible
80%
after deductible
80%
after deductible
100%
100%
80%
80%
after deductible
after deductible
100%
100%
100%
100%
100%
80%
after deductible
80%
after deductible
80%
after deductible
80%
after deductible
100%
after $ 50 co-pay
(waived if admitted)
after deductible
after deductible
after deductible
Physician Office Visit
Allergy Shots (injections)
100%
100%
Physical Therapy
100%
Allowable Non-Surgical Back Treatment
($1000 per Calendar Year
Infertility Treatment & Related Charges (
25,000 LifeTime Maximum)
TMY
Diagnostic X-ray & Lab
Preventive Care:
Well Child Care (birth to age 19)
Immunizations (birth to age 19)
Annual Pap Smears
100%
100%
Mammogram Screening
100%
Adult Physical ( age 19 and over)
100%
after $ 15 co-pay
plus co-pay if there is an
office visit
plus co-pay if there is an
office visit
plus co-pay if there is an
office visit
plus co-pay if there is an
office visit
plus co-pay if there is an
office visit
plus co-pay if there is an
office visit
plus co-pay if there is an
office visit
(maximum $500 per Calendar Year)
HOSPITAL AND OTHER CHARGES
Hospital Room & Board
100%
Emergency Room Charges
100%
Maternity Services
Same Day (Outpatient) Surgery
Anesthesiologists, Radiologists,
Pathologists
100%
100%
100%
Pagine 2 di 6
after $ 50 co-pay (waived if
admitted)
80%
80%
80%
MENTAL ILLNESS, DRUG/ALCHOOL
ABUSE
Impatient Mental Illness (30 days per
Calendar Year)
Outpatient Mental Illness (30 visits per
Calendar Year)
Impatient Drug/Alchool Abuse (30 days
per Calendar Year) (7 days for
detoxification)
Outpatient Drug/Alchool Abuse (60 visits
per Calendar Year)
100%
80%
after deductible
100%
80%
after deductible
100%
80%
after deductible
100%
80%
after deductible
Medical Coverage
In-Network Benefits
Out-of-Network Benefits
OTHER EXPENSES
Skilled Nursing with preauthorization
(100days per Calendar Year)
Hospice Care ($10.000 Lifetime
Maximum including Counseling - $300
limit - Bereavement -$200 limit)
Home Health Care with preauthorization
(100 visits per Calendar Year)
Durable Medical Equipment ($5,000 per
Calendar year)
Prosthetics ($5,000 per Calendar year)
Wigs ($500 Lifetime Maximum) Benefit
only per alopecia resulting from
chemotherapy
Private Duty Nursing (outpatient) with
preauthorization ($25,000 Lifetime
Maximum)
Allowable Foot Treatment
Pagine 3 di 6
100%
80%
after deductible
100%
80%
after deductible
100%
80%
after deductible
100%
80%
after deductible
100%
100%
80%
80%
after deductible
after deductible
100%
80%
after deductible
Not covered
Not
covered
Prescription Drug Coverage
Maximum Benefit
Unlimited
Dispensing Limits
30 day supply per prescription and 90 day supply per prescription
for Mail Order Drugs
Retail Drugs Participating Pharmacy
Brand Name Drug Co-pay Amount
Formulary
Non-formulary
Generic Drug Co-pay Amount
$15 per prescription.
$40 per prescription.
$5 per prescription.
20% coinsurance up to a $100 maximum per prescription subject
to an annual out of pocket maximum of $5,000 per person
Self-Injectables
Non-Participating Pharmacy
Co-pay Amount - The Co-pay shown under the Participating Pharmacy plus 25% of the discounted cost of the prescription.
Self-Injectables are subject to 50% coinsurance.
Mail Order Drugs
Brand Name Drug Co pay Amount
Formulary
Non-formulary
Generic Drug Copay Amount
OFFICE
$30 per prescription
$80 per prescription
$10 per prescription
N. OF EMPLOYEES
Sex
N.
male
Chicago
single
married
4
6
4
6
3
1
1
0
1
0
0
11
4
7
4
7
8
6
2
4
2
4
6
31
9
22
14
17
29
59
20
39
25
34
46
Atlanta
New York
female
10
Miami
Los Angeles
N. OF
DEPENDENTS
Marital Status
PREMIUM:
COVERAGE STATUS
N. OF
EMPLOYEES
Single
Employee + spouse
Employee + children
Family
32
6
10
11
Grand Total
Pagine 4 di 6
ESTIMATED
MONTHLY RATES
ESTIMATED
PREMIUM
$682.00
$1,456.00
$1,121.00
$2,019.00
$261,888.00
$104,832.00
$134,520.00
$266,508.00
$5,278.00
$764,748.00
MONTHLY
RATES
$
$
$
$
MONTHLY
PREMIUM
$
$
$
$
2) – PERSONAL AND DEPENDENT DENTAL EXPENSE INSURANCE
Dental Coverage
In-Panel Benefits
Calendar Year Deductible (Waived for Type 1
treatments)
Out-of-Panel Benefits
$ 100 Individual
$ 300 family
Calendar Year Maximum
$1,500
Lifetime Orthodontia maximum (Dependent
Children to age 19)
$1,500
TYPE 1
Preventivate:
100%
100%
80%
80%
50%
50%
50%
50%
exam
X-Rays
Cleaning
Topical Fluoride
TYPE 2
Basic Expenses:
Fillings
Oral Surgery
Anesthesia
Periodontal
Root Canal
TYPE 3
Major Restorative
Crowns
Bridgeworks
Dentures
TYPE 4
Orthodontia
PREMIUM:
COVERAGE STATUS
N. OF
EMPLOYEES
Single
Employee + spouse
Employee + children
Family
32
6
10
11
Grand Total
Pagine 5 di 6
ESTIMATED
MONTHLY RATES
ESTIMATED
PREMIUM
$49.00
$100.00
$94.00
$156.00
$18,816.00
$7,200.00
$11,280.00
$20,592.00
$399.00
$57,880.00
MONTHLY
RATES
$
$
$
$
MONTHLY
PREMIUM
$
$
$
$
3) – LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT
Life/AD&D Plan Options
Elibibility
All active full-time employees
Benefit Amount
$25,000
Guaranteed Issue
$25,000
Reduction Schedule
33% at age 70 and an additionale 33% at age 75
PREMIUM:
COVERAGE STATUS
N. OF
EMPLOYEES
Single
Employee + spouse
Employee + children
Family
32
6
10
11
Grand Total
ESTIMATED
MONTHLY RATES
ESTIMATED
PREMIUM
MONTHLY
RATES
$7.50
$7.50
$7.50
$7.50
$2,880.00
$540.00
$900.00
$990.00
$30.00
$5,310.00
$
$
$
$
MONTHLY
PREMIUM
$
$
$
$
Il sottoscritto, ai sensi degli artt. 47, 48 e 76 del D.P.R. n.445/00 dichiara:
che, con la presentazione dell’offerta, la Compagnia si obbliga all’osservanza di tutte le condizioni
indicate nella documentazione di gara, dichiarando espressamente che l’offerta deve intendersi:
•
•
Remunerativa e quantificata in base ai calcoli di propria convenienza e a proprio completo
rischio;
Omincomprensiva di tutto quanto necessario alla compiuta e adeguata esecuzione dei servizi
assicurativi oggetto di gara e di tutti gli oneri connessi all’espletamento dei servizi stessi;
Data
_________________
Firma leggibile
_____________________________________
Documenti da allegare:
1.
qualora non sia presente I' autentica delIa sottoscrizione, va allegata copia fotostatica di un documento
di identita’ del sottoscrittore
2. nel caso di sottoscrizione da parte di procuratore del legale rappresentante o Agente di
assicurazione regolarmente autorizzato mediante delega o procura, allegare copia conforme
all' originale, delIa relativa delega o procura
Pagine 6 di 6