Fill - Free fillable Global Mission Medical Insuranceapplication (International Medical Group) PDF form

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Global Mission Medical Insurance®application

Global Mission Medical Insurance offers two areas of coverage: Worldwide

or Worldwide Excluding the U.S., Canada, China, Hong Kong, Japan,

Macau, Singapore, and Taiwan. Either area provides 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 Mission 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 Mission Medical Insurance, please see IMG’s

Frequently Asked Questions at imglobal.com/faq.

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 certicate

wordings containing complete terms of coverage are available upon

request. Please contact IMG or your independent insurance producer for

details.

Important Information

SECTION 1. Please complete for all family members applying for coverage

NAME

Please print your name below

HEIGHT WEIGHT

DOB

(MM/DD/YYYY)

COUNTRY

OF CITIZENSHIP

GOVERNMENT ISSUED

ID NUMBER

A. Applicant last, first, middle

Male

Female

__/__/__

B. Spouse last, first, middle

Male

Female

__/__/__

C. First child (below age 19



last, first, middle

Male

Female

__/__/__

D. Second child (below age 19



last, first, middle

Male

Female

__/__/__

E. Third child (below age 19



last, first, middle

Male

Female

__/__/__

Residence address (after this insurance becomes effective)

Street address:

City: State: Country: Postal/Zip Code:

Telephone: Email:

Fax:

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 or any other Applicant 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:

Fax:

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.

FAILURE TO PROVIDE LEGIBLE AND COMPLETE INFORMATION MAY DELAY PROCESSING OF YOUR APPLICATION.

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SECTION 2a. Please answer all questions for the Applicant and for each family member applying for coverage

If yes, show family member

using letters from Section 1

Are you or any other Applicant currently disabled or unable to perform any activity of daily living?

q Yes q No

2. Are you or any other Applicant 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 or any other Applicant 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 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

5. Do you participate in professional sports or are you a commercial pilot?

q Yes q No

If any individual answered YES to any of the above five questions, he or she does not qualify for this insurance. Thank you for your interest.

6. Have you or any family member applying for coverage 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 Mission 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 or any other Applicant 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 or any other Applicant currently pregnant? If yes, please provide due date: __/__/__ (MM/DD/YYYY)

q Yes q No

For questions 9-29: Have you or any family member applying for coverage 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 following:

9. 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

10. 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

11. 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

12. 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

13. Cancer, tumor, cyst, polyp, melanoma, Kaposi’s sarcoma, cell disorder, shingles, lump, calcification, or growth of any kind?

q Yes q No

14. Liver, Pancreas, Gall Bladder or endocrine disorders including, but not limited to: pituitary, thyroid or metabolic disorders, or

obesity?

q Yes q No

15. Kidney, urinary tract functions, kidney or bladder stones or infections?

q Yes q No

16. Respiratory system including, but not limited to: tuberculosis, lung disorders, emphysema, chronic cough, bronchitis, bronchial

asthma, pleurisy pneumonia?

q Yes q No

17. 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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Family Member

(Use letters from Section 1)

Medications and Dosages Conditions

Date(s) of Treatment

(MM/DD/YYYY)

Family Member

(Use letters from Section 1)

Surgeries

Date(s) of Treatment

(MM/DD/YYYY)

18. 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

19. 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

20. 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

21. For male applicants, disorders of the reproductive system, including but not limited to: prostate or elevated PSA level, or erectile

dysfunction?

q Yes q No

22. 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

23. 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

24. 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

25. Do you or any family member applying for coverage currently use or during the past five years have used tobacco in any form?

q Yes q No

26. Any other disease, medical problem, illness, injury or condition of any kind not listed above?

q Yes q No

27. During the last twelve (12) months, have you or any family member applying for coverage 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

28. Have you or any family member applying for coverage 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

29. 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

and for each Family Member for whom it applies (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 (we) hereby subscribe and apply to become beneficiaries

of the Global Medical Services Group Insurance Trust, c/o MutualWealth

Management Group, Carmel, Indiana, or its successor, for Global Mission

Medical® as offered by the Company on the date of its receipt hereof.

I (we) 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 (we) 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 (we) 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 (we) 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 Mission 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 Mission 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

SECTION 3. Medical Information

For any question answered “YES” in Section 2, please identify each Family Member for whom the answer applies (using the corresponding letter(s) from Section

1), and 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.

Family Member

(Use letters from Section 1)

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 any family member 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.

Family Practitioner’s Details - The following information must be completed

Doctor’s Name: Telephone:

Address:

Country: Postal/Zip Code:

Date Last Seen: Reason:

Page 5 0121

Policy or any Certificate of 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

Mission Medical Insurance, I should see IMG’s Frequently Asked Questions

at imglobal.com/faq.

CERTIFICATION I (we) hereby certify, represent and warrant to IMG and

the Company that: (i) I (we) have read the questions contained in this

Application or they have been read to me (us), and I (we) 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 (we) 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 (we) 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 (we) foresee may require treatment in the

future or for which I (we) 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 (we) 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.

SATISFACTION GUARANTY/REVIEW PERIOD It is understood I (we) will

have 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 (we) may cancel this insurance by written request

retroactive to the effective date and receive a full refund of premium.

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 affiliates, 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, specific for the

administration of coverage and benefits, 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.

Global Mission 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, Guardian or Proxy (Relationship to Applicant if signing as Guardian or Proxy) Date: ___/___/____ (MM/DD/YYYY)

X _____________________________________________________________________________________________________________________________

Signature of of Spouse

Date:

___/___/____ (MM/DD/YYYY)

*A guardian’s signature is required for any Applicant under the age of sixteen (16). See Directions for Completing the Application, Page 1, number 2,

regarding Guardian or Proxy signatures.

Page 60121

If accepted for the Global Mission Medical Insurance plan, I (we) understand

that I (we) may qualify for Global Term Life Insurance underwritten by

International Medical Insurance Group via Alstead Re, a segregated cell

company. I (we) 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 (we) hereby incorporate

herein the certifications, representations, understandings, agreements,

acknowledgements, authorizations, and warranties from the foregoing

Application for Global Mission Medical Insurance, and understand and

agree that the terms, conditions, restrictions and penalties thereof shall

likewise apply hereto. I (we) also understand: (i) that in the event IMG does

not accept this Application, its sole obligation is to return the premium to

me (us), (ii) that the death benefit will be determined by my (our) age at

the time of my (our) death, and (iii) that the Master Policy for Global Term

Life Insurance is issued in Bermuda and is governed by its laws.

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 Mission Medical Insurance®.

Global Term Life Insurance

If a U.S. citizen, I (we) understand coverage for Global Term Life Insurance will not be effective prior to the date of my (our) departure from the U.S.

SECTION 4. Please indicate the name of each family member applying for Global Term Life Insurance.

NAME

TERM LIFE

UNIT ONE

TERM LIFE

UNIT TWO

A. Applicant last, first, middle

Yes q No q Yes q No

B. Spouse last, first, middle

Yes q No q Yes q No

C. First child (below age 19



last, first, middle

Yes q No

NOT AVAILABLE

D. Second child (below age 19



last, first, middle

Yes q No

E. Third child (below age 19



last, first, middle

Yes q No

For each individual applying for life insurance, please indicate:

APPLICANT

PRIMARY BENEFICIARY AND CONTINGENT BENEFICIARY NAMES RELATIONSHIP

% OF DEATH

BENEFIT

Primary beneficiary name:

Contingent beneficiary name:

Primary beneficiary name:

Contingent beneficiary name:

Primary beneficiary name:

Contingent beneficiary name:

Primary beneficiary name:

Contingent beneficiary name:

Primary beneficiary name:

Contingent beneficiary name:

X _______________________________________ X _______________________________________ X _______________________________________

Applicant Spouse For Covered Children

(Initial here) (Initial here) (Initial here)

X _________________________________________

__/__/__

X _________________________________________

__/__/__

Signature of Applicant, Guardian or Proxy

Date

(MM/DD/YYYY)

Signature of Spouse

Date

(MM/DD/YYYY)

Page 7 0121

Enter the annual Global Mission Medical Insurance premium for each family

member that corresponds to their age, gender and deductible.

Application cannot be

processed unless this

section is completed.

Primary Applicant

$ ________

Spouse

$ ________

1st Child

$ ________

2nd Child

$ ________

3rd Child

$ ________

GMMI Subtotal

$ ________

Optional Benefits:

Terrorism Rider

(Platinum plan option only. Check the box and enter 1.25 if applicable)

X _________

GMMI Subtotal =

A$ ________

Term Life Unit One $240 X__________ =

B$ ________

Term Life Unit Two $180 X__________ =

C$ ________

Term Life Unit One - Child $100 X__________ =

D$ ________

Dental & Vision Rider:

$570 (worldwide)

or $460 (worldwide excluding) X__________ =

(Applies to all plans except Platinum)

E$ ________

Optional Sports Rider:

$250 X__________ =

(Applies only to Gold and Platinum plan options)

F$ ________

Subtotal (A+B+C+D+E+F) =

G$ ________

$ __________ X __________ + $ ______________ =

Subtotal G Modal Factor Optional Express Mail*

H$ ________

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)

I WOULD PREFER TO RECEIVE AN ELECTRONIC CERTIFICATE

Email:

# of adults applying

# of children applying

of family members applying

SECTION 5. Deductible selection and premium calculation.

Note: Plan option, deductible selection, payment mode and area of coverage must be the same for all family members.

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.

METHOD OF PAYMENT

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

premiums INCLUDING AS DESCRIBED BELOW FOR AUTOMATIC

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 #:

Exp.

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:

REQUESTED EFFECTIVE DATE:

__/__/__ (MM/DD/YYYY)

(Must be within 30 days after signature. Coverage will in no event be effective until

approved.)

Page 80121

CM00501167A201202

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:

Address:

City: State: Postal/Zip Code:

Telephone: Fax:

Email: Website:

Producer Signature:

X __________________________________________

GA #:

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

For other inquiries, call: +1.317.655.4500

Mail: International Medical Group®

2960 North Meridian Street, Ste 300,

Indianapolis, IN 46208-0509 USA

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