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SECTION 1. Please complete all fields when applying for coverage
Please print your name below
A. Applicantlast, first, middle
Global Crew Medical Insurance®application
Important Information
Global Crew Medical Insurance offers two areas of coverage: Worldwide
Coverage or Worldwide Excluding the U.S., Canada, China, Hong Kong,
Japan, Macau, Singapore, and Taiwan. Both areas of coverage provide
coverage 24 hours a day, and you have the freedom to choose any doctor
or hospital for treatment. Please note the risks and subjects of insurance
under this plan are not intended or considered by the Company or IMG to
be resident, located, or to be performed in any particular jurisdiction, and
special eligibility requirements apply.
Important Notice Regarding Patient Protection and Aordable
Care Act (PPACA) Global Crew Medical Insurance is not subject to, and
does not provide benets required by PPACA. PPACA requires U.S. citizens
and certain U.S. residents to obtain PPACA compliant insurance coverage
unless they are exempt from PPACA. Tax penalties may be imposed
on U.S. citizens and U.S. residents who are required to maintain PPACA
compliant coverage but do not do so. 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 your responsibility to determine if PPACA is applicable to you. For
information on whether PPACA applies to you or whether you are eligible
to purchase Global Crew Medical Insurance, please see IMG’s Frequently
Asked Questions at
Also, this insurance is not subject to certain portability, access, renewal or
other requirements of the Health Insurance Portability and Accountability
Act of 1996. Please read and review all of the eligibility requirements,
coverage conditions, and pre-existing condition exclusions carefully
before purchasing coverage. Marketing brochures and certificate wordings
containing complete terms of coverage are available upon request. Please
contact IMG or your independent insurance producer for details.
Residence address (after this insurance becomes effective)
Street address:
City: State: Country: Postal/Zip Code:
Telephone: Email:
Fax: I reside onboard the vessel where I work?
q Yes q No
Vessel Fax (if applicable): Vessel Email (if applicable):
Current/Most recent Vessel Name: Country of Registry:
Is your expected length of residence outside the U.S. at least 6 of the next 12 months?
(If a U.S. citizen and you answered “No,” you are not eligible for coverage.)
Yes q No
U.S. Citizens / U.S. Nationals:
Date you did (or will) depart from the U.S.: __/__/__ (MM/DD/YYYY)
Non-U.S. Citizens:
If a non-U.S. citizen, do you have a Green Card or U.S. visa? If yes, please complete the following:
Green Card?
q Yes q No
a. Type of visa: ___________________ b. Issue date: __/__/__ (MM/DD/YYYY)
c. Expiration date: __/__/__ (MM/DD/YYYY d. Date of arrival in U.S.: __/__/__ (MM/DD/YYYY)
U.S. Visa
q Yes q No
Mailing Address (if different from above)
Street address:
City: State: Country: Postal/Zip Code:
Telephone: Email:
If either address above is in Florida, is the Applicant currently located in Florida?
(Determines applicable Premium tax and will not affect coverage)
Yes q No
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
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.
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SECTION 2a. Please answer all questions for the Applicant applying for coverage
1. Are you currently disabled or unable to perform any activity of daily living?
q Yes q No
2. Are you presently hospitalized, or scheduled for or in need of or been advised that you should have hospitalization or surgery?
q Yes q No
3. Have you ever tested positive for, been diagnosed with, or been treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related
Complex (ARC), Lymphadenopathy Syndrome, Human Immunodeficiency Virus (HIV) or any other Immune System Disorder?
q Yes q No
4. Have you 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
5. Do you participate in professional sports or are you a commercial pilot?
q Yes q No
If you answered YES to any of the above five questions, you not qualify for this insurance. Thank you for your interest.
6. Have you ever applied for or purchased insurance through IMG? (If yes: please provide certificate number, if any, and details.) By checking
yes, you agree to the following: Do you acknowledge that you are applying for an entirely new certificate of coverage and not a renewal or
reinstatement of any prior Global Crew Medical Insurance® certificate(s) that you may have purchased through IMG in the past, and that,
should IMG accept your new application, this would start a brand new coverage period under the terms, conditions and provisions of the
new insurance certificate (including, but not limited to, all eligibility requirements, pre-existing condition and other exclusions, waiting
periods, and benefit limits and sub-limits of the plan), and your new coverage will not qualify for any benefits of continuous coverage based
upon your prior lapsed coverage?
Certificate number:
q Yes q No
7. Have you been diagnosed with or treated for any type of cancer or pre-cancerous condition during the past five (5) years? If yes, please
explain in Section 3.
q Yes q No
8. Are you currently pregnant? If yes, please provide due date: __/__/__ (MM/DD/YYYY)
q Yes q No
9. I certify that I am a Professional Marine Crew Member who currently or usually works aboard a vessel as a full-time seagoing crew member.
I expect to spend a significant period sailing outside of U.S. waters and I do not qualify for adequate coverage under a U.S domestic
insurance plan.
q Yes q No
For questions 10-30: Have you EVER experienced manifestation or symptoms of, suffered from, sought consultation, examination, testing or been treated for,
or been diagnosed with, any disease, condition, illness, medical problem, disorder, sickness or other problem arising from, involving, or relating to any of the
10. Heart, cardiac, cardiovascular and/or circulatory, including, but not limited to: congestive heart failure, heart attack, angina, chest pain,
arteriosclerosis, atherosclerosis, elevated blood pressure, hypertension, swelling of feet/ankles, thrombosis, phlebitis, rheumatic fever, or
heart murmur? If yes, in addition to Section 3, please complete the following:
a) Date of most recent blood pressure reading? __/__/__ (MM/DD/YYYY)
b) Most recent blood pressure reading: _____AS/_____DS
c) Medications taken (types and dosage): ______________________________________________
q Yes q No
11. Blood, blood vessels, spleen, arteries, veins or disorders of the blood, including, but not limited to: anemia, hemophilia, leukemia, hepatitis,
lymph glands, or high cholesterol?
q Yes q No
12. Diabetes, hyperglycemia or hypoglycemia? If yes to diabetes, in addition to Section 3, please complete the following:
a) Diabetic Type: I _____ or II _____
b) Date diagnosed:
__/__/__ (MM/DD/YYYY)
c) Controlled by diet only?
q Yes q No
d) Medications (types and dosage): ___________________________________________________
e) Date of most recent HbA1c test?:
__/__/__ (MM/DD/YYYY)
f) Results of HbA1c test (1 - 10): _______________________________________________________
q Yes q No
13. Asthma or allergies? If yes, in addition to providing explanation in Section 3, please specify which one and complete the following:
a) Date diagnosed: __/__/__ (MM/DD/YYYY)
b) Has hospitalization or emergency room treatment been required?
If yes, describe and list date(s):
__/__/__ (MM/DD/YYYY)
c) Please list known triggers: _________________________________________________________
d) Medications (types and dosage): ___________________________________________________
e) Frequency of attacks: _____________________________________________________________
q Yes q No
14. Cancer, tumor, cyst, polyp, melanoma, Kaposi’s sarcoma, cell disorder, shingles, lump, calcification, or growth of any kind?
q Yes q No
15. Liver, Pancreas, Gall Bladder or endocrine disorders including, but not limited to: pituitary, thyroid or metabolic disorders, or obesity?
q Yes q No
16. Kidney, urinary tract functions, kidney or bladder stones or infections?
q Yes q No
17. Respiratory system including, but not limited to: tuberculosis, lung disorders, emphysema, chronic cough, bronchitis, bronchial asthma,
pleurisy pneumonia?
q Yes q No
18. Mental, emotional and/or nervous system disorders including, but not limited to: psychosis, mental or behavioral disorders, ADD or ADHD,
chemical or drug abuse or dependency, alcoholism, psychiatric counseling and/or support groups, depression, anxiety, chronic fatigue,
or eating or sleeping disorders?
q Yes q No
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Medications and Dosages Conditions
Date(s) of Treatment
Date(s) of Treatment
19. Neurological disorders, including but not limited to: multiple sclerosis (MS), muscular dystrophy, Lou Gehrig’s disease (ALS), Parkinson’s
disease, paralysis, epilepsy, convulsions, seizures, migraines, chronic headaches, stroke, or transient cerebral ischemic attacks?
q Yes q No
20. Muscular, skeletal, spine, bone, or joint, including but not limited to: scoliosis, disc disease or disorder, vertebrae, degeneration, or any
other back or neck condition, rheumatism, arthritis, gout, tendonitis, osteoporosis or inflammation?
q Yes q No
21. For female applicants, miscarriage, complicated pregnancy or delivery, or infertility consultation, advice, and/or disorders of the
reproductive system or of menstruation, including but not limited to: vaginal bleeding, fibroids, nodules or breast cysts, fallopian tubes,
ovaries or uterus, and hormone replacement therapy?
q Yes q No
22. For male applicants, disorders of the reproductive system, including but not limited to: prostate or elevated PSA level, or erectile
q Yes q No
23. Congenital, genetic, hereditary or other birth condition or defect including, but not limited to: mental retardation, Down Syndrome, or
other chromosome disorder, physical disorder, deformity or defect?
q Yes q No
24. Digestive system, stomach, colon, rectum or intestines, including, but not limited to: esophageal regurgitation, gastritis, ulcers, Crohn’s
Disease and/or diverticulitis?
q Yes q No
25. Eyes, ears, nose, mouth, throat or jaw, including, but not limited to: cataracts, glaucoma, nasal septum deviation, chronic sinusitis, or TMJ?
q Yes q No
26. Do you currently use or during the past five years have you used tobacco in any form?
q Yes q No
27. Any other disease, medical problem, illness, injury or condition of any kind not listed above?
q Yes q No
28. During the last twelve (12) months, have you 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 condition? If
yes, please explain in Section 3.
q Yes q No
29. Have you ever been rejected, cancelled, rated, or declined for coverage under any health, life, or disability insurance policy? If yes, please
explain in Section 3.
q Yes q No
30. During the last six (6) months, have you had comprehensive medical coverage?
If yes, present additional fields to collect information:
* Policy, certificate, or ID number: __________________________________________________
* Private insurance or government plan name: ________________________________________
* Insurer or government entity providing the plan: _____________________________________
* Coverage start date:
__/__/__ (MM/DD/YYYY)
* Coverage end date: __/__/__ (MM/DD/YYYY)
* Include proof of coverage document(s):
Sample acceptable documents:
* 1095 Forms
* Explanation of benefits or payment letters from prior insurer or government entity
* Coverage statements from prior insurer or government entity
* Payroll statements reflecting health insurance deductions
* Records of advance payments of the premium tax credit
Yes q No
SECTION 2b. Please list all prescribed and over the counter medications, and any medical treatment in the last twelve months for the Applicant
(use the corresponding letter(s) from Section 1). Please attach additional pages as necessary.
Page 40121
SUBSCRIPTION (For coverage issued by Sirius Specialty Insurance
Corporation): I hereby subscribe to and apply to become a beneficiary
of the Global Medical Services Group Insurance Trust, c/o MutualWealth
Management Group, Carmel, Indiana, or its successor, for Global Medical
Insurance® as offered by the Company on the date of its receipt hereof.
I understand and agree that: (i) no coverage will be effective until this
Application has been duly 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, (iii) IMG and the Company will rely
on the accuracy and completeness of the information provided herein,
(iv) any misrepresentation or omission contained herein will void the
insurance certificate, and any and all claims and benefits thereunder will
be forfeited and waived, (v) by submission of this Application and/or any
future claim for benefits I purposefully initiate and take advantage of the
privilege of conducting business with the Company in Indiana, through
IMG as its selected agent and administrator, and invoke the benefits and
protections of its laws, and (vi) the contract of insurance represented
by the Master Policy and evidenced by the Certificate of insurance shall
be deemed issued and made in Indianapolis, IN, and sole and exclusive
jurisdiction and venue for any court action or administrative proceeding
relating to this insurance shall be in Marion County, Indiana, for which
Applicant(s) hereby consent(s). I agree that Indiana surplus lines law shall
govern all rights and claims arising under this insurance, and trial of any
dispute shall be by the court as fact finder, without a jury.
ACKNOWLEDGEMENT I understand and agree that: (A)(i) marketing
brochures and certificate wordings are available prior to application
upon request, (ii) except for IMG, any insurance agent, broker or other
producer (or their website), if any, involved with respect to the solicitation
of this application is acting solely as my legal agent and representative
and is representing my personal interests, and that such person has no
authority to bind or speak for, and is not acting as the legal agent or
representative of, the Company or IMG, (iii) if IMG accepts my application
WITH Creditable Coverage, then Global Crew Medical Insurance defines
“pre-existing conditions” as: any disease, Illness, Injury or medical
condition, or symptoms linked to such disease, Illness, Injury or medical
condition for which medical advice, diagnoses or Treatment, including
self-treatment, has been sought, recommended or received; or that I
knew or reasonably should have known existed, whether or not I sought
medical advice, diagnosis or Treatment), and covers them unless the pre-
existing condition was not disclosed on my application or is the subject
of special exclusion provided in a Rider to the Certificate of Insurance, (iv)
if IMG accepts my application WITHOUT Creditable Coverage, then Global
Crew Medical Insurance defines “pre-existing conditions” as: any illness,
Injury, sickness, disease, or other physical, medical, mental or nervous
disorder, condition or ailment that, with reasonable medical certainty,
existed at the time of Application or at any time prior to the effective date
of this insurance, whether or not previously manifested, symptomatic or
known, diagnosed, treated, or disclosed to the Company or IMG prior
to the effective date, and including any and all chronic, subsequent or
recurring complications or consequences related thereto or resulting
or arising therefrom, and coverage for pre-existing conditions varies by
plan option (I should consult my plan option to verify coverage) (v) any
disease, Illness, Injury or medical condition that is not disclosed on my
application will never be covered under this certificate or renewal, (vi)
the subjects of insurance applied for are not intended or considered by
the Applicant(s), the Company or IMG to be resident, located, or to be
performed in any particular jurisdiction, and (vii) 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 benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines
and confinement in prison. (viii) the Company, as carrier and underwriter
of the plan, is solely liable for the coverages and benefits to be provided
thereunder, and IMG acts solely as agent for the Company and has no
direct or independent liability under the Master Policy or any Certificate of
Practitioner’s Details - The following information must be completed
Doctor’s Name: Telephone:
Country: Postal/Zip Code:
Date Last Seen: Reason:
SECTION 3. Medical Information
For any question answered “YES” in Section 2, provide complete details of the medical condition at issue, including the name, address and telephone number
of the attending physician(s), hospital(s), clinic(s) and all other healthcare providers involved, diagnosis, all treatment dates, type(s) of treatment, prognosis, and
present course of treatment. Please attach additional pages as necessary. IMG and the Company reserve the right to request additional medical information
prior to acceptance of Application.
Condition(s)/Diagnosis, Prognosis,
Past and Present Course of Treatment(s)
Physician/Hospital/Clinic/Healthcare Provider Name(s),
Address & Telephone
Date(s) of Treatment
If Applicant applying for coverage has ever been rejected, cancelled, rated, or declined for coverage under any health, life, or disability insurance policy (see
Question 28), please explain below.
Page 5 0121
insurance. (B) This insurance is not subject to, and does not provide benefits
required by, PPACA. On January 1, 2014, PPACA required U.S. citizens, U.S.
nationals and certain U.S. residents to obtain PPACA compliant insurance
coverage unless they are exempt from PPACA. Penalties may be imposed
on persons who are required to maintain PPACA compliant coverage but
do not do so. Eligibility to purchase, extend or renew this product, or its
terms and conditions, may be modified or amended based upon changes
to applicable law, including PPACA. It is an insured person’s sole and
exclusive responsibility to determine if PPACA is applicable to them, and
the Company and IMG shall have no liability to any person whatsoever for
their failure to obtain or maintain PPACA compliant insurance coverage.
For information on whether PPACA applies to me or whether I am eligible
to purchase Global Crew Medical Insurance, I should see IMG’s Frequently
Asked Questions at
CERTIFICATION I hereby certify, represent and warrant to IMG and the
Company that: (i) I have read the questions contained in this Application
or they have been read to me (us), and I understand them, (ii) my (our)
responses to the questions are true, accurate, and complete in all respects
as of the date hereof, and that I will supplement such responses prior to the
requested effective date in the event of any change or addition thereto,
(iii) I am (we are) currently in good health and, except for the conditions
and other information disclosed herein, I have not been diagnosed with,
sought consultation or been treated for, and have not experienced
manifestation or symptoms of and do not suffer from any pre-existing
condition which I foresee may require treatment in the future or for which
I intend to claim under this insurance, and (iv) if this Application is signed
as guardian or proxy of the Applicant, the signer warrants their authority
and capacity to so act and bind the Applicant.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 Applicant.
MEDICAL RELEASE I authorize any doctor, practitioner of the healing arts,
hospital, clinic, healthcare related facility, pharmacy, government agency,
insurance agency, insurance company, group policyholder, employee, or
benefit plan administrator having information as to my (our) care, advice,
treatment, diagnosis or prognosis of any physical or mental condition,
and/or employment status, to provide such information to IMG and/or
the Company and my producer/broker involved in procurement of this
application and/or insurance coverage.
15 days from the effective date to review the insurance Certificate and
all benefits, terms, conditions, limitations and exclusions of coverage. If
not completely satisfied, I may cancel this insurance by written request
retroactive to the effective date and receive a full refund of premium.
E-CONSENT The Applicant wishes to receive information and
communicate electronically, and prefers to use an e-mail address rather
than regular mail. The Applicant agrees IMG, its affiliates, and subsidiaries
may provide the insured person with any communications in electronic
format, and paper communications are not required, unless and until the
Applicant withdraws this consent. The Applicant unambiguously gives
consent to the transfer of personal data to entities established in a country
outside the EU Member States. This consent is freely given, specific for the
administration of coverage and benefits, and an informed indication of
the Applicant’s wishes. The Applicant acknowledges and understands 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.
Global Crew Medical Insurance is underwritten by Sirius Specialty Insurance Corporation (publ) as applicable (the “Company”). It is distributed, managed
and administered, as agent for and on behalf of the Company, by International Medical Group® (“IMG®”).
X _______________________________________________________________________________________________________________________________
Signature of Applicant Proxy (Relationship to Applicant if signing as Proxy)
Date: __/__/__ (MM/DD/YYYY)
Page 60121
If accepted for the Global Crew Medical Insurance plan, I understand
that I may qualify for Global Term Life Insurance underwritten by
International Medical Insurance Group via Alstead Re, a segregated
cell company. I do hereby apply to the Global Life Insurance Services
Group Insurance Trust, Bank of Bermuda, Hamilton, Bermuda, for
Global Term Life Insurance as indicated above. I hereby incorporate
herein the certifications, representations, understandings, agreements,
acknowledgements, authorizations, and warranties from the foregoing
Application for Global Crew Medical Insurance, and understand and
agree that the terms, conditions, restrictions and penalties thereof
shall likewise apply hereto. I also understand: (i) that in the event IMG
does not accept this Application, its sole obligation is to return the
premium to me, (ii) that the death benefit will be determined by my
age at the time of my death, and (iii) that the Master Policy for Global
Term Life Insurance is issued in Bermuda and is governed by its laws.
SECTION 4. Global Term Life Insurance Applicant Information.
A. Applicantlast, first, middle
Yes q No q Yes q No
Underwritten by International Medical Insurance Group via Alstead Re, a segregated cell company. Global Term Life Insurance is only available at the time of application for, and
with the purchase of, Global Crew Medical Insurance®.
Global Term Life Insurance
For each individual applying for life insurance, please indicate:
Primary beneficiary name:
Contingent beneficiary name:
If a U.S. citizen, I understand coverage for Global Term Life Insurance will not be effective prior to the date of my departure from the U.S.
X __________________________________________________________________________________
__/__/__ (MM/DD/YYYY)
(Applicant Initials here)
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SECTION 5. Deductible selection and premium calculation.
Check one Plan Option: q Bronze q Silver q Gold q Platinum
Check one Deductible:
q $100 (Platinum only) q $250 q $500 q $1,000 q $2,500 q $5,000 q $10,000 q $25,000 (Gold and Platinum only)
Check one Payment Mode:
q Annual = 1.00 q Semi-annual = 0.55 q Quarterly = 0.28 q Monthly = .10
Check one Area of Coverage:
q Worldwide q Worldwide excluding the U.S., Canada, China, Hong Kong, Japan, Macau, Singapore, and Taiwan
PREMIUM CALCULATION (Applications without payment of premium will not be approved)
Except for Global Group, IMG will not accept wires for semi-annual, quarterly, or monthly payment modes. Alternative payment modes are only accepted
with pre-authorization to debit your credit card on the due date(s) of your future premium installment(s). Annual premiums may be paid by wire transfer,
eCheck (available online), or by credit card. The insurance certificate can be express mailed for an optional $25 fee.
Enter the annual Global Crew Medical Insurance premium.
Application cannot be
processed unless this
section is completed.
Primary Applicant
$ __________
GCMI Subtotal
$ __________
Optional Benefits:
Terrorism Rider
q (Platinum plan option only. Check the box and enter .25 to
the right of the 1 if applicable)
X 1. _________
GCMI Subtotal =
A$ _________
Term Life Unit One $240 =
B$ _________
Term Life Unit Two $180 =
C$ _________
Dental & Vision Rider:
$570 (worldwide) or $460 (worldwide excluding) =
(Applies to all plans except Platinum)
D$ ________
Optional Sports Rider:
$250 =
(Applies only to Gold and Platinum plan options)
E$ _________
Subtotal (A+B+C+D+E) =
F$ _________
$ __________ X __________ + $ ______________ =
Subtotal F Modal Factor Optional Express Mail*
G$ ________
Modal Factors: Annual=1.00 Semi-Annual=.55 Quarterly=.28 Monthly=.10 Premium Amount Due
Note: Choosing the semi-annual payment option (modal payment factor .55) results in total
payments of 110% of the annual premium, choosing the quarterly payment option (modal
payment factor .28) results in total payments of 112% of the annual premium, and choosing the
monthly payment option (modal payment factor .10) results in total payments of 120% of the
annual premium.
*Optional $25 Express mail: Certificate(s) will be express mailed to you after approval
IF YOU CHOOSE EXPRESS MAIL: Please select the address where you would like your
Certificate express mailed (as indicated in Section 1)
Residence address q Mailing address
Other (no P.O. boxes please)
q Wire (annual only) q MasterCard q Visa
American Express q Discover q JCB
Global Group (complete additional insert)
Group Name: ________________________________
eCheck (ACH) available online
(Authorized signature required for credit card payments)
For wire transfer information, please contact IMG. All payments must be
made in U.S. dollars and drawn on a U.S. bank at the time application
for coverage is made. If paying by credit card, I authorize IMG to debit
my credit card for the total amount due. In the event that I have
chosen to pay premiums semi-annually, quarterly, or monthly, I 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 my credit card periodically
as payment installments become due for premiums and renewal
RENEWALS. This authorization will remain in effect until revoked
by me 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. You understand that the
amount we charge for premium may be more than the amount on the
rate sheet based on your medical history and the underwriting process
and you authorize such payment amount.
Credit Card #:
Date: __/__ (MM/YYYY)
(Cannot be earlier than last
premium installment due date)
Authorized Signature: X __________________________________
Name as it appears on card:
Daytime Phone #:
Billing Address:
__/__/__ (MM/DD/YYYY)
(Must be within 30 days after signature. Coverage will in no event be effective until
Page 80121
© 2007-2021 International Medical Group, Inc. All rights reserved.
Send by one of the following secure methods:
Secure Message Center:
Encrypted Email:
Fax: +1.317.655.4505
For other inquiries, call: +1.317.655.4500
Mail: International Medical Group®
2960 North Meridian Street, Ste 300,
Indianapolis, IN 46208-0509 USA
SECTION 6. Renewal Contact Information
Please specify the best way to contact you at renewal:
q Mail (please provide address):
q Fax (please provide fax number):
q Email (please provide email address):
Automatic Renewal Notice
For your convenience, we will notify you of your renewal premium in advance of your renewal date and automatically renew your plan,
thereby preventing any accidental break in coverage at renewal - unless of course you are no longer eligible or we hear from you to the
contrary before renewal.
SECTION 7. Insurance Producer Use Only
IMG Producer Number #: Producer Name:
Company Name:
City: State: Postal/Zip Code:
Telephone: Fax:
Email: Website:
Producer Signature:
X __________________________________________
GA #:
click to sign
click to edit