MP+International Group Application
Page 1 of 2
Plan Option: q Standard Plan q Alternative Plan
Medical Deductible: $ Family Deductible Limit (2x or 3x): Lifetime Maximum: $
q Yes q No Dental Option: q 1 q 2 q 3
Life & AD&D:
q Yes q No Life & AD&D Amount: $
Daily Hospital Indemnity:
q Yes q No Teleconsultation q
Dependent Life Insurance:
q Yes q No
(Life insurance required in order to purchase this benet)
First of the Coverage Month Following ____________ Days of Full-Time Employment
___________ % of Employee Premium ___________ % of Dependent Premium
ELIGIBLE EMPLOYEES Organization must have at least 2 employees enrolled to receive and maintain coverage under the contract)
Number of
Number of
Eligible Employees:
Number of Employees
Applying for Coverage:
Full Legal Name: Doing Business As:
City: State: Postal/Zip Code:
Country: EIN/ TIN: Government Issued ID Number:
Authorized Representative:
Telephone Number: Fax Number:
Requested Eective Date:
___/___/___ (MM/DD/YYYY)
Fulllment Option: q Email q Mail
Communications should be sent via E-mail to:
MyIMG Group Administrator User ID
(6 or more characters): Amount of Premium Deposit: $
I am an authorized representative of the group members and the group members agree to the processing of their personal information to provide the
services they have purchased, including to administer claims, and to receive member communications, in accordance with IMG’s Privacy Policy.
I am an authorized representative of the group members and the group members agree to receive relevant information and other communications from
IMG about insurance coverages and service options. The group members understand that they can withdraw consent at any time.
Please print legibly and complete ALL sections of this application.
Application for Group Insurance
MP+International group insurance is underwritten and oered by:
Sirius International Insurance Corporation, and will be deemed issued and made in Hamilton, Bermuda, governed by Bermuda law, with sole and exclusive
jurisdiction and venue for any legal proceeding relating to this insurance in Hamilton, Bermuda.
Non-Insurance Assistance Services Acknowledgment
The Applicants, by and through its undersigning authorized agent, acknowledge that, due to the relationship between the Applicants and IMG, that individual Members of
the Group may be eligible for other non-insurance services, such as travel assistance services, offered by IMG. The Applicants hereby acknowledge that these services are
not insurance, are not included with the Insurance premium, and are only available for a separate fee. Further, Applicants acknowledge that the services are limited to those
services contracted for pursuant to a Master Services Agreement (“MSA”). The terms of the MSA have been made available for review and agreement by the Applicants
prior to signing this acknowledgment.
q Medical and Security Evacuation Services q Travel Intelligence Portal q Remote Mental Health Services
MP+International Group Application
Page 2 of 2
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:
Encrypted Email:
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, 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 oered 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 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. Rates are based on your submitted census.
International Medical Group reserves the right to adjust the rates from audit date
back to eective 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 benet 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 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 prison.
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.
Certication 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.