Group Life Insurance Enrollment
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All parts of this form must be completed.
Group Employee
Life Enrollment Form
Group Employee Life insurance is a surplus lines product underwritten and oered by Alstead Re, a segregated cell company (publ) (the “Company”); distributed,
managed, and administered, as agent for and on behalf of the Company, by International Medical Group® (IMG®).
PART 1: General Information
Participating Organization: Group I.D. Number:
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
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:
ID Number:
Date of Birth: ___/___/___ (MM/DD/YYYY) Height: Weight:
Date Employed Full-Time:
___/___/___ (MM/DD/YYYY)
Hours Worked
per Week:
Departure Date from Country of Residence:
___/___/___ (MM/DD/YYYY)
Length of Stay (if applicable): Country of Destination (if applicable):
SSN/TIN: Government Issued ID Number:
Communication should be sent via email to:
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.
PART 2: Employee Life Insurance
q 1x Salary q 2x Salary q 3x Salary q Other amount: _________________________
PART 3: Employee Medical Information
The questions below must be accurately answered for all applicants. For any question answered “Yes, please 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), Lympadenopathy 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
Group Life Insurance Enrollment
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Questions 10-26 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 Part 1), and provide complete details of the condition in Part 5, including the contact information
for all medical providers, and information related to the treatment.
Have you or any other applicant applying for coverage ever experienced manifestation or symptoms of, suered 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?
Date of most recent blood pressure reading:
___/___/___ (MM/DD/YYYY)
Most recent blood pressure reading: _______________ AS/ _________________ DS
Medications (Types / Dosage): _________________________________________
q Yes q No
10. Blood, blood vessels, 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, please complete the following:
a) Diabetic Type: I ____ or II ____
b) Date diagnosed:
___/___/___ (MM/DD/YYYY)
c) Controlled by diet only? Yes _____ No _____
d) Medications (Types / Dosage) _______________________________________________________
e) Date of most recent HbA 1c Test:
___/___/___ (MM/DD/YYYY)
f) Results of HbA 1c Test (1-10) ________________________________________________________
q Yes q No
12. Asthma or allergies? If yes, 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 / Dosage) ____________________________________________________
e) Frequency of attacks: ___________________________________________________________
q Yes q No
13. Cancer, tumor cyst, polyp, melanoma, Kaposi’s sarcoma, cell disorder, shingles, lump 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. Neurological disorders, including but not limited to: multiple sclerosis (MS), muscular dystrophy, Lou Gehrig’s disease
(ALS), Parkinsons disease, paralysis, epilepsy, convulsions, seizures, migraines, chronic headaches, stroke, or transient
cerebral ischemic attacks?
q Yes q No
18. Muscular, skeletal, spine, bone, or joint, including but not limited to: scoliosis, disc disease, vertebrae, or any other back
condition, rheumatism, arthritis, gout, tendonitis, osteoporosis or inammation?
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
Group Life Insurance Enrollment
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Question # Applicant
Condition(s)/Diagnosis and
prognosis, past & present
course of treatment
Expenses in
the last 5 years
Dates of
Medical Provider
Name(s), Address, &
19. For female applicants, miscarriage, complicated pregnancy or delivery, or infertility consultation, advice diagnosis or
q Yes q No
20. Congenital, genetic or hereditary 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
21. Digestive system, stomach or intestines, including, but not limited to: esophageal regurgitation, gastritis, ulcers, colon, or
rectum disorders?
q Yes q No
22. Reproductive systems, including but not limited to: prostate or elevated PSA level, vaginal bleeding, broids, nodules or
breast cysts, fallopian tubes, ovaries or uterus?
q Yes q No
23. 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
24. Any other disease, medical problem, illness, injury or condition of any kind not listed?
q Yes q No
25. Do you or any other applicant currently use or during the past ve years have you used tobacco in any form?
q Yes q No
Group Life Insurance Enrollment
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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
Mail: International Medical Group, Inc., 2960 North Meridian Street, Ste 300,
Indianapolis, IN 46208-0509 USA
For Other Inquiries, Call: +1.317.655.4500
SUBSCRIPTION As a condition-precedent to applying for this insurance, the
undersigned, on behalf and with the authority from the Sponsoring Organization
and its individual Participants (“Applicant, You” or Your”), represents and
warrants they are the authorized agent of the Applicant and hereby applies
and subscribes, for and on behalf of each individual enrolled. 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.
APPLICATION The Participating Organization, by its authorized representative,
hereby applies for Group Employee Life insurance coverage as underwritten
and oered by the Company and administered by the Company’s authorized
representative and plan administrator, International Medical Group, Inc. (IMG).
The Applicant understand and agrees that : (i) the Applicant must pay premiums
for the entire period of coverage in advance, and no coverage will be eective
until the required premium has been paid and this application has been
accepted in writing by the Company, (ii) no modication 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 ocer of the Company or IMG, and
(iii) the Company relies on the accuracy, truthfulness, and completeness of the
information provided herein and any misrepresentation or omission contained
herein will void the insurance and any and all claims and benets thereunder will
be forfeited and waived.
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 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 six (6) 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 six (6) months immediately preceding the Insured
persons 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
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
them or on their behalf, has any records or knowledge of their health, has any
information available as to diagnosis, treatment and prognosis with respect to
any physical or mental condition and/or treatment of them, and any non-medical
information about me, to disclose their entire medical record, le, history,
medications, and any other information concerning them and to give any and
all such information to their agent of record and authorized representatives of
Company, IMG, and their aliates, and subsidiaries.
CERTIFICATION The Applicant hereby certies, represents and warrants that: (i)
the Applicant has 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 Applicant, and the
Applicant understands them, (ii) the Applicant is eligible to participate in the
insurance program applied for, (iii) if signed as the legal representative of the
Applicant, the signer warrants their authority of the signer to so at and bind
the Applicant, 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 eective date. The Applicant understand that if premium is returned
unpaid for any reason, coverage becomes null and void.
CARE ACT PPACA: This insurance is not subject to, and does not provide
benets required by, PPACA. PPACA requires U.S. citizens, U.S. nationals and
resident aliens 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 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 the applicants’ responsibility to determine the insurance requirements
applicable to them and the Company and its Administrator shall have no liability
whatsoever, including for any penalties that the applicants may incur, for their
failure to obtain coverage required by any applicable law including without
limitation PPACA.
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 aliates, 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, specic for the administration of coverage and
benets, 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.
Employee Signature: X _______________________________________________________________________ Date: ___/___/___ (MM/DD/YYYY)