Alternate Payee Form
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The Insured Person may complete the information below and submit a request payment of amounts owed under the insurance contract to be sent to an
alternate payee. This form is only a request and International Medical Group, Inc. (“IMG”) may grant the request in its sole discretion. Thus, the Insured Person
may submit this form as a request to IMG that any amounts owed to the Insured Person under the Insured Persons Insurance Contract (comprised by the
application, policy, declaration, and any riders) be sent to an alternate payee, but if, and only if the alternate payee has already paid for medical expenses covered
by the Insurance Contract and the alternate payee is not a medical care provider or an agent, aliate or representative of any medical provider that provided
medical care related to the Insured Person in any way.
INSURED INFORMATION
Name of Insured:
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Insured ID Number:
Mailing Address:
City: State/Province: Postal Code: Country:
Telephone Number: Email:
Insurance Contract Number:
ALTERNATE PAYEE #1 INFORMATION
Name: Amount or Percentage:
Street Address:
Telephone Number: Email:
City: State/Province: Postal Code: Country:
ALTERNATE PAYEE #2 (if applicable)
Name: Amount or Percentage:
Street Address:
Telephone Number: Email:
City: State/Province: Postal Code: Country:
ALTERNATE PAYEE #3 (if applicable)
Name: Amount or Percentage:
Street Address:
Telephone Number: Email:
City: State/Province: Postal Code: Country:
iTravelInsured Alternate Payee Form
Please print legibly and complete ALL SECTIONS (front and back) of this application. Send this form by secure methods only.
Address: IMG iTravelInsured® Claims, P.O. Box 3231, Farmington Hills, MI 48333-3231 USA
Call: 1.866.243.7524 or 1.317.655.9798; Fax: +1.317.927.6882
Email: iTravelClaims@imglobal.com
www.imglobal.com
Alternate Payee Form
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AUTHORIZATION:
By signing below, I, the Insured Person, agree and acknowledge that:
(1) Any payments made to an alternate payee for benets, reimbursements or amounts owed under the Insurance Contract shall discharge IMG’s duties under the
Insurance Contract as if those payments had been made directly to me and that any amounts owed under the Insurance Contract shall be paid to the alternate
payee
(2) This form shall not be used to assign any benets owed to me to any medical care provider and that if any of the alternate payees listed above are medical care
providers who provided care to me or someone covered under my Insurance Contract, this form is null and void
(3) This form—even if signed and authorized—does not alter, amend, or in any way aect the terms and conditions of the Insurance Contract
(4) If there is any conict between this form and the Insurance Contract, the Insurance Contract supersedes this form
(5) even if IMG authorizes the transfer of payment to the alternate payee pursuant to this form, such authorization has no eect on the eligibility of any claim or
the nature, amount or existence of any benet
(6) To the extent required by the laws of my state or any applicable jurisdiction, my spouse has authorized me to sign this document and I will not use this
document to avoid or violate my spouses rights to any community or marital property
Authorized Signature of Insured:
X __________________________________________________________________
Date:
___/___/___ (MM/ DD/YYYY)
Version 0820IN01200789A190725
Wire Transfer Authorization and Agreement
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Message about electronic transmissions: Electronic transmissions via email or fax are not secure and may be intercepted by unauthorized individuals. Please send your
claim form by secure means. If you chose to send by insecure means, such as unsecured email, you agree to accept any and all resulting risk.
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If sending funds outside of the United States, there may be additional, special fund transfer requirements for international transfers.
Please do not send the Terms & Conditions. Please keep this page for your files. For questions, errors, or issues regarding the transaction, visit
www.imglobal.com or call 1.317.655.4500.
ACH Transfer Authorization
and Agreement Form
INSURED (REQUESTOR) INFORMATION
Name of Insured:
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Insured ID Number:
Street Address (No P.O. Box):
City: State/Province: Postal Code: Country:
Telephone Number/Email: Wire sent on behalf of (if applicable):
WIRE TRANSFER CURRENCY SELECTIONS
Check destination:
International (outside U.S.)
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Domestic (inside U.S.)
For international wires, funds will be sent in the currency of the destination country, where available. If you wish for
the funds to be sent in U.S. dollars (Funds will be converted by local bank, unless recipient has a U.S. dollar account), please
indicate by checking this box:
Currency type if international (name of country and unit):
BENEFICIARY (“RECIPIENT”) INFORMATION
Name: Telephone Number/Email:
Address shown on your bank account (no P.O. Box):
City: State/Province: Postal Code: Country:
SWIFT Code
(Required for international payments):
International Bank Account Number (IBAN)
(Required if sending Euros):
BENEFICIARY BANK (“RECIPIENT BANK”) INFORMATION
Bank Name:
Branch address linked to your account:
City: State/Province: Postal Code: Country:
Account Number: ACH Routing Number:
INTERMEDIARY BANK INFORMATION (if applicable)
Bank Name:
Branch address linked to your account:
City: State/Province: Postal Code: Country:
Account Number: ACH Routing Number:
SPECIAL INSTRUCTIONS (i.e. If 100% of the benefits owed should not be transferred to the above Beneficiary bank)
REQUESTOR AUTHORIZATION: By signing below, I request for an accommodation from and for Company to execute the above funds transfer
instruction up to the amount of benefits owed in accordance with under the insurance contract for funds transfers set forth in this agreement. I
understand and acknowledge Recipients may receive less due to fees charged by the Recipients bank and taxes, and any cancellation must occur
within 30 minutes of sending the request, unless the funds have already been picked up or deposited.
Authorized Signature and Date: X_______________________________________________
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nd
Authorized Signature and Date: ___/___/___ (MM/ DD/YYYY)
Please print legibly and complete ALL SECTIONS (front and back) of this form. Mail, fax, or email completed form to:
Address: IMG iTravelInsured® Claims, P.O. Box 3231, Farmington Hills, MI 48333-3231 USA,
Call: 1.866.243.7524 or 1.317.655.9798; Fax: +1.317.655.4505
Email: itravelclaims@itravelinsured.com
www.itravelinsured.com
Wire Transfer Authorization and Agreement
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Terms and Conditions for Funds Transfers
By requesting a funds transfer order with International Medical Group, Inc., its affiliates, or its subsidiaries (the “Company”), you agree to the following:
Reliance by Company. Company may rely on the information on the form received by it in making your funds transfer. Any errors in the information, including
misidentification of Beneficiary(ies), Recipient(s), incorrect or inconsistent account names and numbers, identifying numbers of the intermediary bank or Beneficiary
Bank, and misspellings, are your responsibility. If you identify a Beneficiary or other entity by name and account or any other number, payment may be made on the
basis of the number and your payment will be final even if the number you provided does not correspond to your Beneficiary or other entity that you have identified.
Bank Fees. Your financial institution may be authorized to debit your account for any fees, costs, or charges related to your funds transfer order. You may have further
authorized your financial institution to charge your account a service fee for each funds transfer order you place in accordance with its fee schedule in effect from
time to time
Transfer of Beneficiary Bank. When you place an order with Company for a funds transfer, you must select a financial institution as the Beneficiary Bank for the
transfer. For transfers within the United States, the Beneficiary Bank must be a member of the Federal Reserve System or a correspondent bank of such a member,
or a Clearing House Interbank Payment System (CHIPS) member. You may request that the funds either be deposited to a particular account at the Beneficiary
Bank or that they be held at the Beneficiary Bank for your Beneficiary. The Beneficiary Bank will be responsible for following your instructions and for notifying the
Beneficiary that the funds are available. After the funds are transferred to the Beneficiary Bank, they become the property of the Beneficiary Bank. The Beneficiary
Bank is responsible to locate, identify, and make payment to your Beneficiary. If your Beneficiary cannot be properly identified, the funds may be returned.
Currency of Transfer. Funds transfers to beneficiaries within the United States are made only in U.S. dollars. For funds transfers to beneficiaries and Beneficiary
Banks in other countries, unless you choose to send U.S. dollars, the transfer will be made in the currency of that country. For such funds transfers, the financial
institution will convert your U.S. dollar payment to the local currency at that financial institution’s exchange rate in effect at that time. The exchange rate usually
includes a commission to the financial institution for exchanging the currency. Because of the laws of some countries in which Beneficiary Banks are located, if you
request a transfer in U.S. dollars the Company cannot guarantee that your Beneficiary will be able to receive U.S. dollars. If your transfer must be converted to the
local currency, the Beneficiary Bank may charge a fee for this exchange. Regardless of the currency transferred, the actual amount that your Beneficiary receives may
be reduced by charges imposed by the Beneficiary Bank, including those for exchanging currency.
Means of Transfer. Company uses a variety of banking channels and facilities to make funds transfers, but will ordinarily use electronic means. The Company may
choose any conventional means that the Company considers suitable to transfer your funds to your Beneficiary. Because the Company does not maintain banking
relations with every bank, the Company sometimes uses one or more intermediary banks to transfer your funds to the Beneficiary Bank. After the Company transmits
your order to an intermediary bank, that bank is responsible to complete your order.
Recalls/Amendments. You may recall or amend your funds transfer order only if the Company receives your request prior to our execution of the funds transfer
order and at a time that provides Company a reasonable opportunity to act upon that request. If your funds transfer order has been executed by Company, the order
can be recalled and amended only if the Beneficiary Bank consents to such a request. Company will not be liable to you for any loss resulting from the failure of the
Beneficiary Bank to recall or amend your funds transfer order. If you decide you want to recall your funds transfer order and your order has already been executed by
Company, you will first have to check with the Beneficiary Bank to determine whether the Beneficiary Bank can return your funds. If the Beneficiary Bank confirms
that the funds are returnable and the funds are returned to Company by the Beneficiary Bank, Company may then send a check for the funds to you. The amount
that is returned to you may be less than you originally transferred because of service charges of the Beneficiary Bank or Company. Your check will be in U.S. dollars.
If your funds transfer was in a foreign currency, your U.S. dollar check will be at the exchange rate on the date of the check.
Rejection of an Order. The Company reserve the right to reject your funds transfer order. The Company may reject your order if you have insufficient information,
the order does not comply with applicable laws, the order is inconsistent with rules and regulations of the financial institutions involved, if your order is incomplete
or unclear, or if the Company is unable to fulfill your order for any other reason including but not limited to force majeure events.
Delays, Non-Execution of Funds Transfer Order. While the Company will handle your funds transfer order as expeditiously as possible, you agree that Company
will not be responsible for any delay, failure to execute, or misexecution of your order due to circumstances beyond Company’s reasonable anticipation or control–
including without limitations any inaccuracy, interruption, delay in transmission, or failure in the means of transmission, whether caused by strikes, power failures,
equipment malfunctions, or acts or omissions of any intermediary bank or Beneficiary Bank. Company MAKES NO WARRANTIES, EXPRESS OR IMPLIED–INCLUDING
THE FAILURE OF ANY INTERMEDIARY BANK OR Beneficiary BANK TO CREDIT YOUR Beneficiary WITH THE AMOUNT OF THE FUNDS TRANSFER AFTER RECEIPT OF SAME
WITH RESPECT TO ANY MATTER.
Cut-Off Time For Executing Your Funds Transfer Order. If your funds transfer order is received by Company at or after its established cut-off hour for receipt of
funds transfer orders, the earliest your funds transfer order can be executed is the next banking day following receipt of all required information.
Claims. You agree that within one hundred eighty (180) days after you receive notification that your funds transfer order has been executed, you will tell Company
of any errors, delays or other problems related to your order. Company will determine whether an error occurred within 90 days after you contact Company and
any error will be corrected promptly. Company will tell you the results within 3 business days after completing the investigation. If Company decides there was no
error, a written explanation will be sent to you. You may ask to appeal an adverse decision by supplying copies of any documents related to the transaction. If your
funds transfer order is delayed or erroneously executed as a result of Companys error, Company’s sole obligation to you is to pay via check such amounts as may be
required by applicable law. In no event shall Company be responsible for any consequential or incidental damages or expenses in connection with your order. Any
claim for interest payable by Company shall not be at any published savings account rate in effect within the state of execution of the funds transfer. In any event,
if you fail to notify Company of any claim concerning your funds transfer order within one year from the date that you receive notification that your order has been
executed, any claim by you will be barred under applicable law.
Governing Law. The Agreement will be governed by the laws of the state of Indiana which is the location through which you initiated this funds transfer and United
States federal law as applicable.
Indemnity. In consideration of the agreement by Company to act upon funds transfer instructions in the manner provided in this Agreement, you agree to
indemnify and hold Company harmless from and against any and all claims, suits, judgments, executions, liabilities, losses, damages, costs, and expenses–including
reasonable attorney’s fees–in connection with or arising out of Company acting upon those funds transfer instructions pursuant to this Agreement. This indemnity
will be effective to relieve and indemnify Company against its negligence or misconduct.
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IMG affiliates and subsidiaries currently include the following companies: iTravelInsured, AkesoCare Management, IMG Europe, International Medical Administrators, Inc.,
Global Response Ltd., and The IMG Foundation.
Version 0719IN01200789A190725