To Enroll in Patriot Executive Medical Insurance:

1. Print and complete entire Enrollment Form.

2. Please make check or money order payable to IMG and enclose in envelope with signed Enrollment Form.

3. Mail to:
IMG
407 North Fulton Street
Indianapolis, Indiana
46202 U.S.A.

Please Print lnsured's Name

Mr. / Mrs. / Ms

(Last)______________________________________________________

(First)_____________________________(Middle)__________________

Send Confirmation of Coverage to:

Name _____________________________________________________________

Address___________________________________________________________

___________________________________________________________________

Phone(______)__________________________

Requested effective date of Coverage______/_____/______

Passport#____________________________________________

Insured's Beneficiary________________________________________________

Insured's U.S. Insurance Carrier & Policy Number_____________________________________________

Individual to notify in case of emergency____________________________

Tel #____________________

Beneficiary's Relationship to Insured_______________________________________

Insured will be the beneficiary for spouse and dependent children

Check or money order should be made payable to IMG. All Premium Payments must be made in U.S. dollars and drawn on a U.S. bank at the time application for coverage is made. If paying by credit card I authorize IMG to bill my Visa/MasterCard/AMEX account for the total charge as specified . Coverage purchased by credit card is subject to validation and acceptance by credit card company.

I understand this policy is not a general health insurance policy. It is intended for the use of the Insured and the Insured's dependents in the event of a sudden and unexpected illness or injury arising when the Insured is eligible for coverage under this insurance. This policy does not provide benefits for illness or injuries which existed during the five years prior to the effective date of this insurance. The undersigned hereby subscribes to the Group Health, Accident and Travel Insurance Trust, in Washington D.C. and enrolls in Patriot Executive ^sm Insurance under contract by Sirius International Insurance Company (publ). If signed as agent of the Insured, the undersigned warrants his authority and capacity to so act, By acceptance of coverage, the Insured ratifies the authority of the signatory to bind Insured. Further, Insured agrees to limitation of coverage for pre-existing conditions as defined herein.

I hereby declare that all persons named in this application are in good health and will not travel unless they are in good health and fit to undertake each insured trip nor will they travel against medical advice or for the purpose of obtaining medical treatment or where they are aware of reasons that could result in a loss during an insured trip.

I further declare that all persons named herein are residents of the United States. I agree that this application shall be the basis for this insurance.

I am in good health and I have not been diagnosed with and do not suffer from any Medical Condition for which I foresee that I may require treatment in the future or for which I intend to claim under this policy. Further, I agree that I am not currently traveling outside of the United States to seek medical treatment or against the advice of a physician. I understand that there is no coverage if I have undertaken a trip outside of the United States against the advice of a physician.

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, Inc.

I understand that coverage under Patriot Executive ^sm is NOT RENEWABLE, and that I must pay premium for the entire coverage period in advance. Any successive enrollments in Patriot Executive are not renewals.

Signature_______________________________________ Date____/____/____

Address_________________________________________________________

________________________________________________________________

Phone(______)___________________________________________________


Names of individuals to be covered under this policy:

Date of Birth  

Insured (first name)

Spouse ____/____/____ $_________

Child ____/____/____ $_________

Child ____/____/____ $_________

$$Total $_________

Method of Payment: [ ] Check [ ] Money Order [ ] Master Card [ ] Visa[ ] AMEX

Credit Card #________________________ Exp.___________ Date_________________________

Name as it appears on card_________________________Signature_________________________

Daytime Phone_________________________

Billing Address_________________________________________________