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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:
Address:
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
(MM/DD/YYYY)
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.
