Patriot Travel Medical Insurance

PATRIOT TRAVEL MEDICAL INSURANCE^sm
Medical Insurance for Citizens Traveling Abroad

To Enroll in Patriot Travel Medical Insurance^sm:

1. Print this Page
2. Complete entire Enrollment Form.
3. Please make check or money order payable to IMG and enclose in envelope with signed Enrollment Form.
4. Mail to:
IMG
407 North Fulton Street
Indianapolis, Indiana
46202 U.S.A.

Applicant information: Patriot Travel Medical Insurance^sm Please print clearly

(Circle one) Mr. Mrs. Ms.

Last Name_______________________________

First Name___________________________Middle________________

Passport Number____________________________________

Issuing Country__________________________________

Send Confirmation of Coverage to:

Name__________________________________________________________________________

Address________________________________________________________________________

City_________________________________State_________Zip

Code__________________Country_____________

Beneficiary_________________________________________

Relationship to Applicant__________________________

Insured will be beneficiary for spouse & children

Calculating Your Premium:

Select the coverage plan and plan option: (Check one plan and one option).

Patriot International^sm	Opt 1__	Opt 2__	Opt3___
Patriot America^sm	Opt 4__	Opt 5__	Opt6__
ExPatriot Plus^sm	Opt 7__	Opt 8__	Opt 9__	Opt 10__

Names of Persons to be insured		Date of Birth	Monthly Premium	15 Day Premium
Applicant	_______________________	___/___/___	___________	___________
Spouse	_______________________	___/___/___	___________	___________
Child	_______________________	___/___/___	___________	___________
Child	_______________________	___/___/___	___________	___________
Please Attach additional sheet for more children			___________	___________
			Total (A)	Total (B)
Requested Effective Date ___/___/____ Expected Date of Departure____/____/___ Date of Return to Home Country ____/___/___

_________	x	_________	=	_________	+	_________	=	_________
(A)		Number of months				(B)		(C)

_________	X	_________	=	_________	X	_________	+	_________	=	$_________
(C)		Deductible factor (see below)		(D)		Sports Rider Factor (see below)		US$15.00 Optional Overnight, Fax confirmation or Special Correspondence		Total Premium

Deductible	Discount factor
$250	1
$500	.90
$1000	.80
$2500	.70
Sports factor	1.2

Payment must be for total number of months you want coverage. Refund of premium will be made only if a written request is received by IMG prior to the effective date of coverage. After that, the premium is fully earned and non refundable. All payments must be made in US Dollars.

Payment Method Check (To IMG) / Money Order (To IMG) / Mastercard / Visa / Amex

Card #_____________________________________________

Expiration date___________ Phone________________________________

Name on Card________________________________________________Signature______________________________

If paying by credit card, I authorize IMG to bill my credit card account for the total charge as specified if Total Premium. Coverage purchased by credit card is subject to validation and acceptance by credit card company. The undersigned hereby subscribes to the Global Health, Accidental and Travel Insurance Trust, in Washington D.C. and enrolls in Patriot Travel Medical Insurance^sm ( under contract by Sirius International Insurance Corporation (publ). If signed as proxy of the Insured, the undersigned warrants their authority of the signatory to bind insured. 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. Further, insured agrees to exclusion of coverage for pre-existing conditions as defined here-in. 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. The undersigned authorizes any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance agency, insurance company, group policy holder, 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. I understand that coverage under Patriot International^sm ( & or Patriot America^sm) is NOT Renewable and that I must pay premium for the entire coverage period in advance. Any successive enrollments in Patriot International^sm ( & or Patriot America^sm) are not renewals.

x___________________________________________

Signature of Insured or Proxy

Date__________________ Phone_________________

Address_____________________________________

____________________________________________

Selling Agent Use Only

Agency#_______________________________

Name__________________________________

Address________________________________

City________________State____Zip Code____

PATRIOT INTERNATIONAL^sm
For U.S. CitizensTravel Medical Insurance for U.S. citizens traveling abroad. Patriot International^sm has 3 benefit options.

PATRIOT AMERICA^sm
For Non-U.S. Citizens U.S style Travel Medical Insurance for non-U.S. citizens traveling outside their country of citizenship. Patriot America has 3 benefit options.

EXPATRIOT PLUS^sm
For All Long Term Travelers. ExPatriot Plus^sm must be issued for a minimum of 6 months and is renewable for up to 2 years. ExPatriot^sm has a $1,000,000 benefit.

Premiums effective through 12/31/99.

*A dependent child is your child shown on the Enrollment Form under 18 years of age, traveling with you, and for whom premium has been paid.