MP+International Group Application
Page 2 of 2
WWW.IMGLOBAL.COM
CM00501204A201217 0121
Authorized Representative Signature: X _________________________________________________ Date: ___/___/___ (MM/DD/YYYY)
Printed Name: Title/Position:
Producer Signature: X _________________________________________________________________ Date: ___/___/___ (MM/DD/YYYY)
Printed Name:
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
REQUESTED ASSISTANCE SERVICES
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, to
the Conyers Trust Company (Bermuda) Limited, Richmond House, 12 Par-la-Ville
Road Hamilton HM 08, Bermuda, or its successors, for the insurance coverage
requested above and as underwritten and oered by Sirius International
Insurance Corporation on the date of its receipt hereof, and as administered
by the Company’s authorized representative and Policy Manager, International
Medical Group, Inc (IMG).
APPLICATION The Participating Organization, by its authorized representative,
hereby applies for MP+ International insurance coverage as underwritten
and oered 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 eective
until the required premium has been paid and this application has been
accepted in writing by the Company, (ii) no modication 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 ocer 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 benets thereunder
will be forfeited and waived. Rates are based on your submitted census.
International Medical Group reserves the right to adjust the rates from audit date
back to eective date if any of the following changes occur or are discovered
after the date of the proposal: Enrollment =/- 10%, Average Contact Size +/-
10%, Area Factor +/- 7.5%, Age/Sex Factor +/- 10%, Any Material Changes, Less
than 100% of all eligible employees enroll in an employer sponsored plan, less
than 80% of all benet eligible employees (including spousal waivers) enroll
with International Medical Group. Please also not that plans do not include a
provision for 4Q deductible carryover or deductible credit from prior carrier.
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 fulllment 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 eective 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 Eective 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 benets 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 benet or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to nes and
connement 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, benet 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 aliates, and subsidiaries.
Certication The Applicant hereby certies, 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 eective 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
benets 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 modied 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.
ECONSENT. 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 aliates, 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, specic for the administration of coverage and
benets, 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.
