Fill - Free fillable Group Employee Life Enrollment Form Occupation: Annual Salary (International Medical Group) PDF form

0521

Group Life Insurance Enrollment

Page 1 of 4

WWW.IMGLOBAL.COM

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

0521

Group Life Insurance Enrollment

Page 2 of 4

WWW.IMGLOBAL.COM

PART 4.

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), Parkinson’s 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

0521

Group Life Insurance Enrollment

Page 3 of 4

WWW.IMGLOBAL.COM

PART 5: ADDITIONAL INFORMATION

Question # Applicant

Condition(s)/Diagnosis and

prognosis, past & present

course of treatment

Expenses in

the last 5 years

Dates of

Treatment

(MM/DD/YYYY)

Medical Provider

Name(s), Address, &

Telephone

19. For female applicants, miscarriage, complicated pregnancy or delivery, or infertility consultation, advice diagnosis or

treatment?

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

0521

Group Life Insurance Enrollment

Page 4 of 4

WWW.IMGLOBAL.COM

CM00501366A210427

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

PART 6: CERTIFICATION AND AGREEMENT

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

person’s 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

prison.

AUTHORIZATION FOR RELEASE OF INFORMATION. The Applicants authorize

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.

IMPORTANT NOTICE REGARDING PATIENT PROTECTION AND AFFORDABLE

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)

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Group Employee Life Enrollment Form Occupation: Annual Salary (International Medical Group)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Group Employee Life Enrollment Form Occupation: Annual Salary (International Medical Group) Form

Related forms

Fillable Group Employee Life Enrollment Form Occupation: Annual Salary (International Medical Group)

Fill Online, Printable, Fillable, Blank Group Employee Life Enrollment Form Occupation: Annual Salary (International Medical Group) Form

Related forms

First 20 documents completely FREE!