Global Medical Insurance Application

GLOBAL MEDICAL INSURANCE^SMUnderwritten By: Sirius International Insurance Corporation

IMPORTANT INFORMATION REGARDING THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)

This insurance is not subject to certain access and renewal requirements of the Health Insurance Portability and
Accountability Act of 1996. You should therefore read the coverage conditions and preexisitng condition exclusions
carefully before purchasing coverage.

Important Information About This Application:
U.S. Citizens: If you or any family member to be included in this insurance are located in the U.S. on the date of this
Application the effective date will be the later of:
A. The date requested on the Application;or
B. The date the Applicant departs the U.S.;or
C. The date the Applicant is approved by IMG^sm.

Non-U.S. Citizens: If you or any family member to be included in this insurance are located in the U.S. on the date of this
Application and do not plan on leaving the U.S. an Affidavit of Eligibility is required. Note, a new Affidavit of Eligibility will
be required at each renewal.

SECTION 1 Please Complete for all Family Members
^{Please print your name as you would like it to appear on your ID card}
Name	Sex	Height	Weight	Date of Birth MM. D. Yr.	Country of Citizenship	Passport or Social Security #
^{A. Applicant} __________________	M F
^{B. Spouse}__________________	M F
^{C. 1st Child} __________________	M F
^{D. 2nd Child} __________________	M F
^{E. 3rd Child} __________________	M F

ADDRESS OF RESIDENCE OUTSIDE THE US
Street Address:				City:		Postal Code:
State:	Country:		Telephone:
Fax:			E-mail Address:
Date of or Date you will Depart from the US?			Expected Length of Residence Outside the US?
Mail Forwarding Address if Different From Above
Street Address:				City:		Postal Code:
State:	Country:	Telephone:			Fax:

SECTION 2		Family Member
Please Answer All Questions for Applicant and each Family Member.		(Use letters from Sect. 1)
Are you currently disabled, pregnant or unable to perform normal activities?	Yes No
Are you presently hospitalized?	Yes No
Have you ever been diagnosed, treated or tested for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), Lymphadenopathy Syndrome, Human Immunodeficiency Virus (HIV), or any other Immune System Disorder?	Yes No
Have you been diagnosed or treated for Cancer during the past five (5) years?	Yes No
If any individual answered YES to any of the above questions, they are not eligible for this insurance. Thank you for your interest.

SECTION 3
Questions 1 - 16 must be answered for every Family Member included on this Application. For any question that has been answered "YES," please state which Family Member (using the corresponding "Letter" from Section 1), provide details of the medical condition including treatment dates, name, address and phone number of the attending physician, diagnosis, prognosis, and present course of treatment in the space provided in Section 5 of this Application or in the space provided on the Additional Information page, Section 7. The Company reserves the right to request additional medical information.
		Family Member (Use letters from Sect. 1)
1. During the last 12 months has anyone been diagnosed with any medical condition, or received treatment (including medications or consultations) for any medical, mental or nervous condition? If yes, please explain:	Yes No
2. Has anyone ever been rejected, rated or declined for any other Health, Life or Disability Policy? If yes, please explain:	Yes No
Has anyone ever been treated for or been told that they have any of the following diseases, conditions, medical problems, disorders, sicknesses or problems relating to any of the following:		Family Member (Use letters from Sect. 1)
3. Heart, Cardiac, Cardiovascular, or Circulatory Condition?	Yes No
4. Blood vessels, Arteries or Blood Pressure? (If yes, provide most recent BP reading)	Yes No
5. Migraines, Headaches or Stroke	Yes No
6. Diabetes ( If yes, please complete supplemental Diabetes Questionnaire)	Yes No
7. Cancer, Tumor Cyst, Polyp, Lump or Growth of any kind?	Yes No
8. Liver, stomach, gall bladder, colon or intestines?	Yes No
9. Kidney or Prostate? (including testing or examination of the Prostate Gland)	Yes No
10. Lung, respiratory system or asthma?	Yes No
11. Mental, nervous or neurological? Drug Abuse or Alcoholism??	Yes No
12. Bone or Skeletal, including any disorder of the Knee, Hip or Back?	Yes No
13. Reproductive systems (including miscarriage or other complications of pregnancy or delivery)?	Yes No
14. Does anyone use tobacco in any form?	Yes No
15. Any other illness, injury or condition not stated above?	Yes No
16. Has anyone ever purchased insurance through IMG^SM? If yes, policy number:_____________	Yes No

I hereby certify that I have read the above statements or that they have been read to me and that the above statements are true and complete to the best of my knowledge and belief. I understand that any misrepresentation contained herein will void the contract and any and all claims will be forfeited.

I understand that any medical condition that existed prior to the date I am accepted for coverage will be excluded from coverage for two years, whether or not that condition is disclosed on this Application. Further, I understand that after two years, coverage for pre-existing conditions will be limited to US $25,000 lifetime.

I understand that no coverage is effective until the date specified by the Company on the Certificate after this Application is accepted by an authorized representative of the Global Medical Services Group Insurance Trust, Union Federal Savings Bank, Indianapolis, Indiana.

I understand that the Master Policy is issued in the United States and is governed by its laws.

The undersigned authorizes any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance agency, insurance company, group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial and employment status, of the insured to provide this information to International Medical Group^SM, Inc.

The undersigned, solemnly declare that Applicant and all Family Members listed in this Application are in good health and except for the conditions disclosed on this Application, have not been diagnosed with and do not suffer from any medical, mental or nervous condition which they foresee may require treatment in the future or for which they intend to claim under this policy.

We understand that a physical exam may be required by the Company prior to acceptance.

_______________________________________		_______________________________________
Signature of Applicant or Guardian		Signature of Spouse
_______________________________________		_______________________________________
Date of Signature		Date of Signature

GLOBAL TERM LIFE INSURANCE^* & GLOBAL DAILY INDEMNITY^*

Underwritten By: Certain Underwriters at Lloyd's, London.
Distributed and Administered By: International Medical Group^SM, Inc.

*Global Term Life and Global Daily Indemnity are only available at time of Global Medical Application with purchase of Global Medical Insurance^SM.

To Apply, Simply Complete The Following Application.

SECTION 4 Please Indicate Name of Each Family Members Applying for Life Insurance and/or Global Daily Indemnity.
Name (Last, Middle, First)	Basic Life	Supplemental Life	Daily Indemnity
^A. ^Applicant ___________________________________	Yes No	Yes No	Yes No
^B. ^Spouse ___________________________________	Yes No	Yes No	Yes No
^C. ^{1st Child} ___________________________________	Yes No	Not Available	Yes No
^D. ^{2nd Child} ___________________________________	Yes No		Yes No
^E. ^{3rd Child} ___________________________________	Yes No		Yes No

FOR EACH INDIVIDUAL APPLYING FOR LIFE INSURANCE, INDICATE:

Primary Beneficiary:

Percent of Death Benefit

______________________________________
^Name
______________________________________
^{Address of Beneficiary}

_________________%