^$500

^{Deductible Plan}

^$1,000

^{Deductible Plan}

^$2,500

^{Deductible Plan}

^$5,000

^{Deductible Plan}

^Male

^Female

^Male

^Female

^Male

^Female

^Male

^Female

^{First 2 Free, Then 380}

^{First 2 Free, Then 290}

^{First 2 Free, Then 260}

^{First 2 Free, Then 250}

⁴⁰⁰

⁴⁰⁰

³¹⁰

³¹⁰

²⁸⁰

²⁸⁰

²⁷⁰

²⁷⁰

^{*First two (2) children free between the ages of 14 days to 9 years only when both parents are insured under the Global Medical InsuranceSM plan.}

^{Dependent child rate only available when parent (guardian) is insured under the Global Medical InsuranceSM plan.}

⁹²⁵

^1,585

⁷²⁰

^1,140

⁶³⁵

^1,010

⁵²⁰

⁸³⁰

^1,025

^1,750

⁷⁹⁵

^1,260

⁷⁰⁰

^1,115

⁵⁷⁵

⁹¹⁰

^1,080

^1,940

⁸⁴⁰

^1,445

⁷⁴⁵

^1,280

⁶¹⁰

^1,050

^1,195

^2,090

⁹²⁵

^1,600

⁸²⁰

^1,415

⁶⁷⁰

^1,135

^1,330

^1,675

^1,030

^1,300

⁹¹⁵

^1,155

⁷⁴⁵

⁹⁴⁵

^1,470

^1,845

^1,140

^1,435

^1,010

^1,270

⁸²⁵

⁹⁸⁰

^1,800

^2,020

^1,400

^1,575

^1,275

^1,430

^1,045

^1,170

^2,210

^2,210

^1,725

^1,725

^1,565

^1,565

^1,280

^1,280

^3,075

^2,885

^2,575

^2,385

^2,350

^2,175

^1,950

^1,725

^6,615

^5,715

^6,115

^5,215

^4,755

^4,280

^4,125

^3,700

^8,150

^7,020

^7,645

^6,520

^6,010

^5,400

^5,260

^4,700

^8,545

^7,360

^8,045

^6,860

^6,330

^5,685

^5,540

^4,950

^8,970

^7,725

^8,470

^7,220

^6,670

^5,990

^5,840

^5,220

^8,415

^8,100

^8,915

^7,600

^7,025

^6,305

^6,150

^5,500

^9,885

^8,500

^9,385

^8,000

^7,400

^6,645

^6,485

^5,800

^{Please print your name as you would like it to appear on your ID card.}

^Name

^Height

^Weight

^{Date of Birth}

^{Country of}

^Citizenship

^{Passport or}

^{Social Security #}

^{Mth. Day Yr.}

^{Family Member}

^{(Use letters from Sect. 1)}

^{Have you tested positive, been diagnosed, or treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), Lymphadenopathy Syndrome, Human Immunodeficiency Virus (HIV), or any other Immune System Disorder?}

^{If any individual answered YES to any of the above questions, they are not eligible for this insurance. Thank you for your interest.}

^{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 GroupSM, 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}

^{Name (Last, Middle, First)}

^{Basic Life}

^{Supplemental Life}

^{Daily Indemnity}

^{£ yes £ no}

^{£ yes £ no}

^{£yes £ no}

^{£yes £ no}

^{£ yes £ no}

^{£yes £ no}

^{£yes £ no}

^{£yes £ no}

^{£ yes £ no}

^{£yes £ no}

^{£ yes £ no}

^{£yes £ no}

^{Name Relationship}

^{____________________________________________________________________________}

^{Address of Beneficiary}

^{B. ____________________________________________________________________________}

^{Name Relationship}

^{____________________________________________________________________________}

^{Address of Beneficiary}

^{C. ____________________________________________________________________________}

^{Name Relationship}

^{____________________________________________________________________________}

^{Address of Beneficiary}

^{_________________%}

^{_________________%}

^{Name Relationship}

^{_____________________________________________________________________________}

^{Address of Beneficiary}

^{B. _____________________________________________________________________________}

^{Name Relationship}

^{_____________________________________________________________________________}

^{Address of Beneficiary}

^{C. _____________________________________________________________________________}

^{Name Relationship}

^{_____________________________________________________________________________}

^{Address of Beneficiary}

^{Note: Beneficiaries for other dependent children may be placed in Section 8.}

^{Percent of Death Benefit}

^{_________________%}

^{_________________%}

^{_________________%}

^{Applicant Spouse For Covered Children}

^{If accepted for the Global Medical InsuranceSM plan I understand that I qualify for Global Term Life Insurance underwritten by Certain Underwriters at Lloyd’s, London.}

^{I do hereby apply to the Global Life Insurance Services Group Insurance Trust, Bank of Bermuda, Hamilton, Bermuda for Global Term Life Insurance. I understand that any misrepresentation contained on my Global Medical Application or this Application will void the contract and any and all claims will be forfeited. If I have also applied for the optional Global Daily Indemnity plan, I understand that only overnight hospital stays eligible}

^{under my Global Medical InsuranceSM plan, excluding pregnancies, are covered. I also understand there is an additional premium for Global Daily Indemnity.}

^{I understand that in the event the Company does not accept this Application, their sole obligation is to return the Premium to me. I understand that the Death Benefit will be determined by my age at the time of my death.}

^{I understand that the Master Policy is issued in Bermuda and is governed by its laws.}

^{_________________________________________________ _________________________________________________}

^{Signature of Applicant or Guardian Signature of Spouse}

^{_________________________________________________ _________________________________________________}

^{Date of Signature Date of Signature}

^{Credit Card #___________________________________________________________________________ Exp. Date_______________}

^{Name as it appears on card______________________________________ Signature X_________________________________________}

^{Daytime Phone# (_________)____________________________ Billing Address_________________________________________}

^{________________________________________________________________________________________________________________________________________________Check or money order should be made payable to IMGSM. All payments must be made in US dollars at the time Application for coverage is made. If paying by credit card, I authorize IMGSM to debit my Visa/MasterCard/American Express account for the total amount due. In the event that I have elected to *PRE-AUTHORIZE credit card payment installments, I hereby request and authorize IMGSM to charge my credit card periodically as payment installments become due. This authorization will remain in effect until revoked by me in writing, and until IMGSM actually receives notice. Coverage purchased by credit card is subject to validation and acceptance by credit card company. *For any mode other than Annual, I pre-authorize IMGSM to debit my credit card for the proper installment amount on the due date of the installment.}

^{Agent Number #: 16926}

^{Agent Name: Kenton Henry}

^{Company Name: All Plan Med. Quote}

^{Address: 7 Switchbud Place, Bldg C-192 #250,}

^{City: The Woodlands}

^{State: TX}

^{Zip : 77380}

^{Phone: 281-367-6565}

^{Fax: 281-362-0261}

^{E-Mail quote@allplaninsurance.com}

^{X_______________________________________________ (Agent Signature)}

^{Family Member}

^{(Use letters from Sect. 1)}

^{Name Relationship}

^{____________________________________________________________________________}

^{Address of Beneficiary}

^{E. ____________________________________________________________________________}

^{Name Relationship}

^{____________________________________________________________________________}

^{Address of Beneficiary}

^{Percent of Death Benefit}

^{_________________%}

^{_________________%}

^{Name Relationship}

^{____________________________________________________________________________}

^{Address of Beneficiary}

^{E. ____________________________________________________________________________}

^{Name Relationship}

^{____________________________________________________________________________}

^{Address of Beneficiary}

^{_________________%}

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the BlueCross and Blue Shield Association
Copyright ©, All Rights Reserved