Group Application
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Application for Group Insurance
Medical Deductible: $ Family Deductible Limit (2x or 3x): Lifetime Maximum: $
o Yes o No Dental Option: o 1 o 2 o 3
Life & AD&D:
o Yes o No
($10,000 minimum required on groups less than 11 employees)
Life & AD&D Amount: $
Daily Hospital Indemnity:
o Yes o No (Life insurance required in order to purchase this benefit)
First of the Coverage Month Following ____________ Days of Full-Time Employment
___________ % of Employee Premium ___________ % of Dependent Premium
ELIGIBLE EMPLOYEES Organization must have at least 2 employees enrolled to receive and maintain coverage under the contract)
Number of
Number of
Eligible Employees:
Number of Employees
Applying for Coverage:
Your GEO group insurance is underwritten and offered by Sirius International Insurance Corporation (the “Company”) and will be deemed
issued and made in Hamilton, Bermuda, governed by Bermuda law, with sole and exclusive jurisdiction and venue for any legal proceeding
relating to this insurance in Hamilton, Bermuda.
Full Legal Name:
City: State: Postal/Zip Code:
Country: EIN/ TIN: Government Issued ID Number:
Authorized Representative:
Telephone Number: Fax Number: Requested Effective Date:
___/___/___ (MM/DD/YYYY)
Fulfillment Option: o Email o Mail
Communications should be sent via E-mail to:
MyIMG Group Administrator User ID
(6 or more characters): Amount of Premium Deposit: $
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.
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.
Group Application
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APPLICATION. The Participating Organization (Applicant), by its authorized representative, hereby applies for GEO insurance coverage as
underwritten and offered by the Company and administered by the Company’s authorized representative and plan administrator, International
Medical Group (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 effective until the required premium has been paid and this application has been accepted in writing by the
Company, (ii) no modification 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 officer of the Company or IMG, and (iii) the Company relies on the accuracy, truthfulness, and completeness of the
information provided in this form or previously provided to IMG or the Company in the GEO RFP. Any misrepresentation or omission contained
herein or on the GEO Group RFP, will void the insurance and any and all claims and benefits 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 fulfillment 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,
and a complete copy of the insurance contract, including all exclusions, can be accessed at imglobal.com/sample-contracts, (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 benefits
to be provided under the insurance contract and IMG has no direct or independent liability under any insurance contract.
PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA). This insurance is intended for Participating Organizations with members on
expatriate status (members who have a good faith belief that they will reside outside of their Home Country for at least six months during a
plan year) and their Spouses and Dependents. This insurance is regulated by a foreign government, and is considered to be Minimum Essential
Coverage under the U.S. Patient Protection and Affordable Care Act (PPACA) for each month when the member (i) is outside of the U.S. for at
least one day of that month or (ii) is physically present in the U.S. for an entire month if the coverage provides health benefits within the U.S.
while the member is on expatriate status. Eligibility to purchase or renew this product, or its terms and conditions, may be modified or amended
based upon changes to applicable law, including PPACA. Please note that it is solely the Applicant’s responsibility to determine the insurance
requirements that are applicable to it and the Company and IMG shall have no liability whatsoever, including for any penalties that Applicant or
any of its members may incur, for failure to obtain coverage required by any applicable law, including without limitation PPACA.
CERTIFICATION. The Applicant hereby certifies, represents and warrants that : (i) the Employees have 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 Employees, and the Employees understand them, (ii) the Employees are eligible to participate in the insurance program applied for,
(iii) if signed as the legal representative of the Employee, the signer warrants their authority and capacity to so act and to bind the Employees.
By acceptance of coverage and/or submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the
Employees, 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 effective date. The Applicant understands that if premium is returned unpaid for any reason, coverage becomes null and void.
Authorized Representative Signature: X _________________________________________________ Date: ___/___/___ (MM/DD/YYYY)
Printed Name: Title/Position:
Producer Signature: X _________________________________________________________________ Date: ___/___/___ (MM/DD/YYYY)
Printed Name:
International Medical Group®
P.O. Box 88500, Indianapolis, IN 46208-0500
Phone: 1.317.655.4500 or 1.800.628.4664, Fax: 1.317.655.4505
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