Fillable Form 1: International Marine Medical Insurance (IMMI) Group (International Medical Group)

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Form 1: International Marine Medical Insurance (IMMI) Group (International Medical Group)

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IMMI Group Enrollment Form Page 1 of 3 0121
Participating Organization:
Vessel Name: Group/ Vessel I.D. Number:
(A) Full Legal Name:
(Last, First, Middle)
Citizenship:
Are you a U.S. citizen or resident required to le a U.S. tax return?
q Yes q No
SSN/TIN: Passport/ID Number:
q Male q Female
Occupation: Annual Salary (Required if applying for a life
amount based on 1x, 2x, or 3x salary):
Requested Eective Date:
__/__/__
(MM/DD/YYYY)
Mailing Address: City: State/Country:
Postal/Zip Code: Telephone: Country of residence:
Date of Birth: __/__/__
(MM/DD/YYYY) Height: Weight: Hours Worked per Week:
Date Employed Full-Time:
__/__/__ (MM/DD/YYYY)
Are you presently, or have you ever been, enrolled in Medicare Part A or Part B q Yes q No
Medicare ID number: Communication should be sent via email to:
q I agree to the processing of my personal information to provide the services I have purchased, including to administer claims, and to receive member
communications, in accordance with IMG’s Privacy Policy, found at imglobal.com/legal/privacy-policy.
q I agree to receive relevant information and other communications from IMG about Insurance coverages and service options. I understand that I can
withdraw my consent at any time.
Late enrollees or groups with less than 20 covered employees must complete the entire form
Groups with 20 or more employees must complete the entire form excluding sections 4 and 5
International Marine Medical Insurance
SM
(IMMI)
Group Enrollment/Change Form
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 IMIG, by International Medical
Group®, Inc. (IMG®).
This form is for:
q Employee Only Coverage
q Late Enrollment
q Beneciary Change
q Name Change
q Coverage for Dependents
q Address Change
q Waiver of Coverage
q New Employee
q Termination (Initials:______ )
q Change of Status
q Removal of Dependent(s)
I waive coverage for: q Myself and Family Members q Spouse q Children
Reason: Initials:
Date: __/__/__ (MM/DD/YYYY)
Note: If you wish to apply for coverage for a person who is not waiving coverage, you must complete the rest of the enrollment form. Do not complete the rest
of this form for anyone not applying for coverage.
2
WAIVER OF COVERAGE
Name: (Last, First, Middle)
(DOB) Date of Birth
(MM/DD/YYYY)
(H) Height
(W) Weight
(MCN) Medicare Claim Number if
enrolled and
(SSN) Social Security Number
Passport Number
(B) Spouse:
q Male q Female
DOB:
__/__/__
Date of Marriage:
__/__/__
H:
W:
MCN:
SSN:
(C) Child:
q Male q Female
DOB: __/__/__
H:
W:
MCN:
SSN:
(D) Child:
q Male q Female
DOB: __/__/__
H:
W:
MCN:
SSN:
(E) Child:
q Male q Female
DOB: __/__/__
H:
W:
MCN:
SSN:
3
DEPENDENTS (attach an additional form for more dependents) q I am enrolling dependents q I am removing dependents
1
GENERAL INFORMATION
IMMI Group Enrollment Form Page 2 of 3 0121
The questions below must be accurately answered for all applicants. For any question answered “Yes,” identify to whom the answer applies (use
the letter that corresponds to the applicant from Parts 1 and 3), and provide complete details of the condition in Part 5, including the contact
information for all medical providers, and information related to the treatment. IMG and the Company reserve the right to request additional
information following review of the answers.
1. Are you or any other applicant currently disabled, pregnant, or unable to work or perform activities of daily living?
q Yes q No
2. Are you or any other applicant presently hospitalized, or scheduled for or in need of hospitalization or surgery?
q Yes q No
3. Have you or any other applicant ever tested positive for, been diagnosed with, or been treated for Acquired Immune Deciency
Syndrome (AIDS), AIDS Related Complex (ARC), Lymphadenopathy Syndrome, Human Immunodeciency Virus (HIV) or any
other Immune System Disorder?
q Yes q No
4. Have you or any other applicant ever had mental or nervous system disorders including, but not limited to: psychosis, mental
or behavioral disorders, chemical or drug abused or dependency, alcoholism, psychiatric counseling and /or support groups,
depression, anxiety, chronic fatigue, or eating disorders?
q Yes q No
5. Have you or any other applicant ever had, been recommended to have, or are you currently on a waiting list for any organ
transplant (other than corneal)?
q Yes q No
6. Have you or any other applicant been diagnosed with or treated for any type of cancer or pre-cancerous condition during the
past ve (5) years?
q Yes q No
7. Have you or any other applicant ever been rejected, cancelled, rated or declined for coverage under any health, life or disability
insurance policy?
q Yes q No
8. During the last twelve (12) months, have you or any other applicant experienced manifestation or symptoms of, been diagnosed
with, or received any consultation, examination, testing or treatment (including medications) for, any medical, health, mental
physical or nervous conditions?
q Yes q No
9. Have you ever had insurance through IMG or Sirius International at any time? If yes, please provide us with the policy or
certicate number: ___________________
Your initials here will authorize IMG to cancel existing coverage under your current IMG insurance contract on the same date
that your IMMI Group coverage becomes eective and only if the group coverage is approved. X _____________________
q Yes q No
Have you ever been treated for or been told that you have any illnesses, conditions, medical problems, disorders or problems relating to any of the
following? (Please explain all “yes” responses).
10. Hardening of the arteries or blood vessels
q Yes q No
11. Alcoholism or drug abuse
q Yes q No
12. Liver, stomach, intestine, thyroid, or gallbladder
q Yes q No
13. Kidney/ sugar, protein or blood in urine
q Yes q No
14. Asthma or other disease of the respiratory system
q Yes q No
15. Mental, nervous or neurological
q Yes q No
16. Reproductive organs, including miscarriage or other complication of pregnancy or delivery
q Yes q No
17. Bone skeletal, including any disorders of the knee, hip or back
q Yes q No
18. Migraine headaches or stroke
q Yes q No
19. Colon or prostate (including testing or examination of the prostate gland)
q Yes q No
20. Do you use tobacco in any form
q Yes q No
21. Any condition not listed above
q Yes q No
4
MEDICAL QUESTIONS
IMMI Group Enrollment Form Page 3 of 3 0121
Question # Applicant
Condition(s)/Diagnosis and
prognosis, past & present course
of treatment
Expenses in
the last 5 years
Dates of Treatment
(MM/DD/YYYY)
Medical Provider Name(s),
Address, & Telephone
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
1. The person(s) enrolling in this insurance (individually or collectively, “Applicant”) represents
that the responses provided in this enrollment form are true, accurate, and complete for all
persons listed on this application, and that it will supplement such responses prior to the
requested eective date in the event of any change or addition thereto; and that all persons
listed on this application are not currently hospitalized, disabled, or HIV+ as of the requested
eective date.
2. 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 any illness, injury, sickness, disease, or other physical, medical,
Mental or Nervous Disorder, condition or ailment for which: medical advice, diagnosis, care
or Treatment was recommended or received at any time during the three (3) months prior
to the eective date or a condition that would have caused an ordinarily prudent person to
seek medical advice, diagnosis, care or treatment during the three (3) months immediately
preceding the Insured person’s Initial Eective Date, (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.
3. The Applicant understands and agrees that, 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.
4. The Applicant agrees to receive information and communicate electronically, and prefers
to use email rather than regular mail. The Applicant agrees that IMG may provide any
communications in electronic format, and IMG is not required to send paper communications,
unless and until the Applicant withdraws this consent. The Applicant also agrees to be
responsible for providing IMG with true, accurate and complete email address, contact, and
other information related to this insurance coverage, and to maintain and promptly update
any changes in this information.
FRAUD NOTICE 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 Applicant hereby authorizes
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 the Applicant or on the Applicant’s behalf,
has any records or knowledge of the Applicant’s health, has any information available as to
diagnosis, treatment and prognosis with respect to any physical or mental condition and/
or treatment of the Applicant, and any non-medical information, to disclose Applicant’s
entire medical record, le, history, medications, and any other information concerning the
Applicant and to give any and all such information to the Applicant’s agent of record and
authorized representatives of Company, IMG, and their aliates, and subsidiaries.
6
EMPLOYEE BENEFICIARY INFORMATION
Beneciary Name Relationship
Birth Year
(MM/DD/YYYY)
Percent of Benet
Primary Beneciary #1: __/__/__
Primary Beneciary #2: __/__/__
Contingent Beneciary #1: __/__/__
Contingent Beneciary #2: __/__/__
5
ADDITIONAL INFORMATION
7
CERTIFICATION AND AGREEMENT
CM00501217A201221
By requesting life insurance and/or any future claim for life benets I (we) purposefully initiate and take advantage of the privilege of conducting business with International Medical
Insurance Group via Alstead Re, a segregated cell company, through IMG as its managing general underwriter and plan administrator, the life insurance contract represented by its Master
Policy and evidenced by that Certicate of insurance will be deemed, issued and made in Hamilton, Bermuda, and sole and exclusive jurisdiction and venue for any legal proceeding relating
to the life insurance will be in Hamilton Bermuda, for which the applicant(s) hereby consent(s). I (we) consent and agree that Bermuda law shall govern all rights and claims raised under
the life insurance contract.
Employee Signature:
Date: __/__/__ (MM/DD/YYYY)
Spouse Signature:
Date: __/__/__ (MM/DD/YYYY)
X
X
Note: When sending payment information, health information and other documents and data regarding your condential personal information, please send by
secure means only.
Send by one of the following secure methods: Secure Message Center: https://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
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Form 1: International Marine Medical Insurance (IMMI) Group (International Medical Group)

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Completed 14 June 2021

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