CM00501310A210304 0121
PART 4 LIFE INSURANCE BASED UPON MULTIPLE OF EMPLOYEE’S SALARY (if applicable)
q 1x Salary q 2x Salary q 3x Salary q Other Amount:
By requesting life insurance and/or any future claim for life benets I (we) purposefully initiate and take advantage of the privilege of conducting business
with International Medical 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 Certicate 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.
EMPLOYEE BENEFICIARY INFORMATION
Beneciary Name Relationship Birth Year Percent of Benet
Primary Beneciary #1:
___/___/___
Primary Beneciary #2:
___/___/___
Contingent Beneciary #1:
___/___/___
Contingent Beneciary #2:
___/___/___
PART 5 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,
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.
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 (dened as a pre-existing condition), 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.
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 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.
BENEFITS CHANGE INFORMATION: EMPLOYER USE ONLY
Eective Date: ___/___/___ (MM/DD/YYYY)
Change of Status (Check one):
q Return to the U.S.
Date of Return: ___/___/___
(MM/DD/YYYY)
q Return to overseas assignment
Date of Return: ___/___/___
(MM/DD/YYYY)
Employee Signature: X _______________________________________________________________________ Date: ___/___/___ (MM/DD/YYYY)
Authorized Representative Signature: X _________________________________________________________ Date: ___/___/___ (MM/DD/YYYY)
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
