Fillable Form 1: Application for Group Insurance International Marine (International Medical Group)

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Form 1: Application for Group Insurance International Marine (International Medical Group)

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The Form 1: Application for Group Insurance International Marine (International Medical Group) form is 3 pages long and contains:

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  • 27 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

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0121
WWW.IMGLOBAL.COM
International Marine Medical Insurance
SM
(IMMI)
Page 1 of 3
Full Legal Name: Vessel Name:
Address:
City: State: Postal/Zip Code:
Country: EIN/ TIN: Government Issued ID Number:
Authorized Representative:
Telephone Number: Fax Number: Requested Eective Date:
___/___/___ (MM/DD/YYYY)
Fulllment Option: q Email q Mail
Communications should be sent via email to:
MyIMG Group Administrator User ID
(6 or more characters): Amount of Premium Deposit: $
q I am an authorized representative of the group members and the group members agree to the processing of their personal information to provide the services they
have purchased, including to administer claims, and to receive member communications, in accordance with IMG’s Privacy Policy.
q I am an authorized representative of the group members and the group members agree to receive relevant information and other communications from IMG about
insurance coverages and service options. The group members understand that they can withdraw consent at any time.
q International Marine Medical Insurance q International Marine Medical Insurance Platinum
Dental:
q Yes q No Life & AD&D**: q Yes q No
Daily Hospital Indemnity:
q Yes q No (Life insurance required in order to purchase this benet)
___________ % of Employee Premium ___________ % of Dependent Premium
Number of Employees: Number of Eligible Employees: Number of Employees Applying for Coverage:
First of the Coverage Month Following ____________ Days of Full-Time Employment
(number)
International Marine Medical Insurance
SM
(IMMI)
Application for Group Insurance
International Marine Medical Insurance is a fully insured group benet plan. The medical portion of the benet plan is underwritten by Crum & Forster SPC, a member
of the Crum & Forster Group of Companies and is available to members of the Fairmont Specialty Trust, LTD, c/o ITA Global Trust LTD, Camana Bay, Grand Cayman.
**The Life portion of the benet plan is underwritten by International Medical Insurance Group via Alstead Re, a segregated cell company distributed, managed and
administered, as agent for IMG, by International Medical Group®, Inc. (IMG®).
1
PROSPECTIVE PARTICIPATING ORGANIZATION (“APPLICANT”)
2
EMPLOYEE WAITING PERIOD FOR FUTURE EMPLOYEES
3
EMPLOYER CONTRIBUTION
4
ELIGIBLE EMPLOYEES Organization must have at least 2 employees enrolled to receive and maintain coverage under the contract)
5
CHOOSE A PLAN
Send by one of the following secure methods:
Secure Message Center: www.imglobal.com/secure-message-center
Encrypted Email: insurance@imglobal.com
Fax: +1.317.655.4505
Mail: International Medical Group, Inc., 2960 North Meridian Street, Ste 300,
Indianapolis, IN 46208-0509 USA
For Other Inquiries, Call: +1.317.655.4500
Please print legibly and complete ALL sections of this application
Medical Deductible: $ Family Deductible Limit (2x or 3x): Period of Coverage Maximum: $
0121
WWW.IMGLOBAL.COM
International Marine Medical Insurance
SM
(IMMI)
Page 2 of 3
CREDIT CARD AUTHORIZATION
Credit Card Number:
Expiration date:
Name as it appears on card:
Billing address:
__________________________________________________
_________________________________________________________________
Phone number:
Email address:
Authorized signature on card:
ECHECK PAYMENT INFORMATION
Name of Participating Organization (the Employer)
applying for group
coverage:
_______________________________________________________
Please include the following e-Check information on the account:
_________________________________________________________________
Name(s) on account:
Account number:
Routing number:
Select
One
q Commercial Checking q Consumer Checking
q Consumer Savings
Routing Number Account Number
attach your void check here
All e-Check payments must be made in U.S. or Canadian dollars.
Please attach VOID check or DEPOSIT SLIP with this form.
Printed name:
Authorized signature:
X _________________________________________
Title (if applicable):
Other comments:
(Initial here)
NOTE: When sending payment information, health information and other documents and data regarding your condential personal
information, please send by secure means only.
By supplying account information, Applicant wishes to pay the premium by credit card or the designated account for each applicant requesting
coverage. If the application is accepted, the credit card or designated account will be billed for the premium at the selected payment mode.
By signing and submitting this form, Applicant represents and warrants that Applicant has the card or account holder’s authorization to use
the account and, if not, will take full responsibility for the payment and any changes accruing to it. By submitting the signed application, the
Applicant agrees to pay via credit card or applicable account the premium amount owed and have read and agree to all terms, conditions,
and other statements in this application. The Applicant hereby authorizes IMG to debit their payment type for the total amount due. In the
event that the Applicant has chosen to pay premiums semi-annually, quarterly, or monthly, they hereby elect to pre-authorize future credit card
payment installments for the balance of the policy period and for renewals, and hereby request and authorize IMG to charge the credit card
periodically as payment installments become due for premiums and renewal premiums. The Applicant hereby requests and authorizes IMG to
secure premium payments with the selected check information.
This authorization will remain in eect until revoked by the Applicant in writing,
and until IMG actually receives the notice of revocation. Coverage purchased by credit card is subject to validation and acceptance by the credit
card company. The Applicant understands that they will be given advance notice of the renewal premiums and that they may vary each year.
6
MODE AND METHOD OF PAYMENT Name of Participating Organization (The Employer) Applying for Group Coverage
Mode of Payment:
Select
One
q Monthly q Quarterly q Semi-Annual q Annual
Method of Payment:
Select
One
q Check q Money Order q e-Check q American Express
q Visa q MasterCard q Discover q Wire Transfer/ ACH
If Paying by
Credit Card:
Select
One
q I want the selected credit card to be debited
ONLY for the 1st premium payment, based
on the selected Mode of Payment.
q Until further notice, I want the selected credit card to be debited for
ALL premium payments (current and future), based on the selected Mode
of Payment. I have the right to change the Method of Payment at any time.
Checks and Money Orders should be made payable to International Medical Group (IMG).
All payments must be made in U.S. dollars and drawn on a U.S. bank at the time of application for coverage to be bound.
If paying by credit card, I authorize IMG to debit the above indicated credit card account for the total amount due, based on the selected Mode of Payment.
This Authorization will remain in eect until notication is received from the Sponsoring Organization (the Employer).
0121
WWW.IMGLOBAL.COM
International Marine Medical Insurance
SM
(IMMI)
Page 3 of 3
SUBSCRIPTION
I hereby apply to be a Plan Participant of Fairmont Specialty Trust (the “trust”) and
to participate in the insurance coverage extended by certain underwriters at HDI
Global Specialty (“the insurers”) to Plan Participants under the trust (the “coverage”).
I understand that the coverage is not a general health insurance prodcut, but is
intended for use in the event of a sudden and unexptected event while traveling
outside my home country. I understand that the coverage extended to me will
terminate upon my return to my home country unless I qualify for a benet
period or home country coverage. I understand that I may obtain full details of
the coverage by requesting a copy of the master policy from the plan manager. I
understand that the liability of the Insurers as underwriters of the coverage is as
provided in the master policy. By acceptance of coverage and/or submission of
any claim for benets, the Plan Participant raties the authority of the signer to
so act and bind the Plan Participant. The Plan Participant undertakes to make all
premium payments as they fall due in respect of the coverage extended to them.
The trustee shall not be responsible for the administration of such payments. If
the Plan Participant fails to make any premium payment due in respect of the
coverage extended to them, subject to the discretion of the insurance company,
such coverage will lapse. The Plan Participant hereby conrms the accuracy of all
information validity of all representations and warranties provided to the trustee
in connection with its participation in the Plan and/or the subscription for the
insurance coverage, howsoever provided, including the terms of this subscription
agreement, (together “representations & warranties”). The Plan Participant
acknowledges that certain of such information will be relied upon by the Insurers
as providers of the coverage and that any inaccuracy therein may result in the
invalidity of such coverage as it relates to the Plan Participant, the loss of coverage
and all monies paid in relation thereto. The Plan Participant hereby undertakes
to inform the trustee of any change to any of matter that forms the subject of
any of the representation & warranties. The Plan Participant hereby undertakes to
indemnify and hold harmless the trustee against any loss of damage (including
attorney’s fees) occasioned by any inaccuracy in any representation & warranty
or failure to advise the trustee of any change in any matter that forms the subject
of any of the representation & warranties. The Plan Participant agrees that the
trustee shall be entitled to rely on and to act in accordance with any written
instruction purported to be provided by the Plan Participant and the Plan
Participant hereby undertakes to indemnify and hold harmless the trustee against
any loss or damage (including attorney’s fees) occasioned by the trustee acting in
accordance with any such instruction. Payments under the terms of the coverage
shall be paid by the insurers to the Plan Participant or directly to a provider if
assignment of benets has been authorized. The trustee shall not be responsible
for the administration of such payments. I conrm that I have satised myself that
the coverage is appropriate for me and that I meet the eligibility criteria.
APPLICATION
The Participating Organization, by its authorized representative, hereby applies
for International Marine Medical Insurance (IMMI) insurance coverage as
underwritten and oered by the Company and administered by the Company’s
authorized representative and plan administrator, International Medical Group,
Inc. (IMG). The Applicant understands and agrees that : (i) the Applicant must pay
premiums for the entire period of coverage in advance, and no coverage will be
eective until the required premium has been paid and this application has been
accepted in writing by the Company, (ii) no modication or waiver relating to
this application or the coverage applied for will be binding upon the Company
or IMG unless approved in writing by an ocer of the Company or IMG, and
(iii) the Company relies on the accuracy, truthfulness, and completeness of the
information provided herein and any misrepresentation or omission contained
herein will void the insurance and any and all claims and benets thereunder will
be forfeited and waived. Rates are based on your submitted census. International
Medical Group reserves the right to adjust the rates from audit date back to
effective date if any of the following changes occur or are discovered after the
date of the proposal: Enrollment +/- 10%, Average Contract Size +/- 10%, Area
Factor +/- 7.5%, Age/Sex Factor +/- 10%, Any Material Changes, Less than 100%
of all eligible employees enroll in an employer sponsored plan, Less than 80% of
all benefit eligible employees (including spousal waivers) enroll with International
Medical Group. Please also note that plans do not include a provision for 4Q
deductible carryover or deductible credit from prior carrier.
ACKNOWLEDGEMENT
The Applicant understands and agrees that: (i) the insurance producer/agent/
broker soliciting, assigned to, or assisting with this application is the agent and
representative of the applicant(s) and IMG acts in fulllment of its contractual
duties to the Company and on behalf of the Company, (ii) this insurance contains
a number of exclusions from coverage, including an exclusion for pre-existing
conditions, in order to review all coverage details a complete copy of the insurance
contract, including all exclusions, may be provided upon request, (iii) the subjects
of insurance applied for are not intended or considered by the Applicant, the
Company or IMG to be resident, located, or expressly to be performed in any
particular jurisdiction, and (iv) the Company, as carrier and underwriter of the
insurance plan, is solely liable for the coverages and benets to be provided
under the insurance contract and IMG has no direct or independent liability
under any insurance contract, (v) the Applicants also agree it is their responsibility
to provide IMG with true, accurate and complete e-mail address, contact, and
other information related to my coverage, and to maintain and promptly update
any changes in this information. Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject
to nes and connement in prison.
AUTHORIZATION FOR RELEASE OF INFORMATION
The Applicants authorize any health plan, health care provider, health care
professional, MIB, federal, state or local government agency, insurance or
reinsuring company, consumer reporting agency, employer, benet plan, or any
other organization or person that has provided care, advice, diagnosis, payment,
treatment, or services to them or on their behalf, has any records or knowledge
of their health, has any information available as to diagnosis, treatment and
prognosis with respect to any physical or mental condition and/or treatment of
them, and any non-medical information about me, to disclose their entire medical
record, le, history, medications, and any other information concerning them
and to give any and all such information to their agent of record and authorized
representatives of Company, IMG, and their aliates, and subsidiaries.
CERTIFICATION
The Applicant hereby certies, represents and warrants that: (i) the Applicant
has read the foregoing statements and any marketing materials and a sample
insurance contract that were made available upon request and prior to the
application or that they have been read to the Applicant, and the Applicant
understands them, (ii) the Applicant is eligible to participate in the insurance
program applied for, (iii) if signed as the legal representative of the Applicant, the
signer warrants their authority of the signer to so at and bind the Applicant, and
(iv) subject to Company’s acceptance of this application and payment of the total
amount due, coverage will begin at 12:01 a.m. on the approved eective date. The
Applicant understand that if premium is returned unpaid for any reason, coverage
becomes null and void.
IMPORTANT NOTICE REGARDING PATIENT PROTECTION AND AFFORDABLE
CARE ACT PPACA
This insurance is intended for Participating Organizations with Employees on
expatriot status (Employees who have a good faith belief that they will reside
outside of their Home Country for at least six (6) months during a plan year) and
thier Spouses and Dependents. This insurance is provided by Crum & Forster
SPC (the Company), located in the Cayman Islands taht is regulated by a foreign
government, and is considered to be Minimum Essential Coverage under the
United States Patient Protection and Aordable Care Act (PPACA) for Each month
when the Employee is outside of the United States for at least (1) day of that month
for when the Employee is physically present in the U.S. for an entire month if the
coverage provides health benets within the United States while the individual
is on expatriate status. Eligibility to purchase or renew this product or its terms
and conditions, may be modied or amended based upon changes to applicable
law, including PPACA. Please note that it is solely the Employee’s responsibility
to determine the insurance requirements that are applicable to him/her and the
Company and IMG shall have no liability whatsoever including for any penalties
that the Employee may incur, for failure to obtain coverage required by any
applicable law including without limitation PPACA.
ECONSENT
The Applicants wish to receive information and communicate electronically,
and prefer to use an e-mail address rather than regular mail. The Applicants
agree IMG, its aliates, and subsidiaries may provide each insured person with
any communications in electronic format, and paper communications are not
required, unless and until the Applicant withdraws this consent. The Applicants
unambiguously give consent to the transfer of personal data to entities established
in a country outside the EU Member States. This consent is freely given, specic
for the administration of coverage and benets, and an informed indication of the
Applicants’ wishes. The Applicants acknowledge and understand the transfer is
necessary for the performance of a contract, taken in response to their request,
and necessary for the conclusion or performance of a contract concluded in their
interest.
7
AUTHORIZATION
CM00501214A201221
Authorized Representative Signature: X _____________________________________________
Date: ___/___/___ (MM/DD/YYYY)
Printed Name: Title/Position:
Producer Signature:
X ______________________________________________________________
Date: ___/___/___ (MM/DD/YYYY)
Printed Name: Producer Number:
(Initial here)
(Initial here)
The Applicant acknowledges and agrees that IMG will automatically renew your coverage by enrolling your group into the then-current IMMI group plan
whose terms shall be those set forth in the then-current and in-force Certicate of Insurance as of the date of such auto-renewal and that IMG shall do so each
year on your certicate anniversary (an “Automatic Renewal”) unless an authorized representative of your group armatively communicates an intention to
non-renew within 30 days of our group anniversary date or as otherwise set forth in the Certicate of Insurance. You will receive an automatic renewal notice
prior to our anniversary date.
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Form 1: Application for Group Insurance International Marine (International Medical Group)

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Completed 14 June 2021

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