Fill - Free fillable iTravelInsured Alternate Payee Form (International Medical Group) PDF form

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 Person’s 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 spouse’s 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.

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.)

 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 Recipient’s 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_______________________________________________

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 Company’s 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.

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

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iTravelInsured Alternate Payee Form (International Medical Group)

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