Fillable iTravelInsured Beneciary Designation Form (International Medical Group)

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iTravelInsured Beneciary Designation Form (International Medical Group)

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Beneficiary Designation Form
Page 1 of 1
iTravelInsured Beneficiary Designation Form
Subject to the terms and conditions of the insurance contract, applicable laws, and any rights of a valid assignee of record, it is requested the beneciary of any
benets payable upon death of the insured be distributed as follows:
Insured’s Name (Last, First, Middle):
Policy Number: Insured’s Date of Birth:
___/___/___ (MM/ DD/YYYY)
Insured’s Signature: X ____________________________________________ Witness Signature: X _____________________________________________
Printed Name: Printed Name:
Date:
___/___/___ (MM/ DD/YYYY) Date: ___/___/___ (MM/ DD/YYYY)
Spouse’s Signature and Consent (if applicable)
2
:
X _______________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
It is understood and agreed upon receipt of this completed, signed, dated designation by IMG, such designation will be eective and relate back to the date it is
signed but without prejudice to IMG on account of any payment made prior to receipt and acknowledgement of the validity of the designation by IMG. International
Medical Group shall not be obligated to honor this designation until it has been received, acknowledged, and determined by IMG to comply with applicable laws.
This designation supersedes and cancels all prior designations by the Insured for any coverage administered by IMG.
The undersigned represents and warrants he/she has not been declared incompetent and no court order or law prevents naming the above beneciary(ies). It is
agreed IMG assumes no responsibility for the validity or eect of any attempted designation or transfer of rights under the insurance contract.
The undersigned also represents and warrants any information and documents provided by the undersigned prior to and after the eective date of coverage and
facts and other matters presented in this form are true and accurate to the best of the undersigned’s knowledge and belief. The undersigned understands and agrees
that a) any coverage or benets are contingent upon statements as being complete and correct and b) benets under any insurance contract will be paid only if the
insurer or IMG decides in its discretion the claimant is entitled to them.
Lack of Notice of Community Property Interest: If IMG has not previously received written notice of a community property interest and if the below consent is not
signed by the person having that interest, IMG shall be entitled to rely in good faith no such interest exists. IMG assumes no responsibility to inquire or validate any
such interest, and in consideration of submitting this designation, the Insured for himself/herself, his/her estate, heirs, successors, and assigns, agrees to indemnify
and hold the insurer and IMG harmless from any consequences of honoring this designation.
1
Total percentage must equal 100% otherwise benets will be paid on a pro-rata basis according to the percentages shown. If no percentage is identied, benets will be paid equally.
2
Spouse’s signature needed only if the Insured or Beneciary resides in a community property state (ie AZ, CA, ID, LA, NM, NV, TX, WA, & WI).
PRIMARY BENEFICIARY(IES)
Name Relationship Address
DOB
(MM/ DD/YYYY)
SSN Percentage
___/___/___
___/___/___
___/___/___
___/___/___
Total
1
CONTINGENT BENEFICIARY(IES) if all Primary Beneciary(ies) predecease you
Name Relationship Address
DOB
(MM/ DD/YYYY)
SSN Percentage
___/___/___
___/___/___
___/___/___
___/___/___
Total
Version 0820IN01200991A200518
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
Wire Transfer Authorization and Agreement
Page 1 of 2
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.
1
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.)
1
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_______________________________________________
2
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
Page 2 of 2
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.
2
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 Beneciary Designation Form (International Medical Group)

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Completed 14 June 2021

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