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Reside® Worldwide
Application for Coverage
2005 Reside Worldwide Medical Plan - All Sections Must be Completed in
Full
As described in the brochure and documentation, RESIDE Worldwide is a
comprehensive medical insurance program designed exclusively for the
international citizen. In order to provide you and your family with the
coverage you desire, please follow the directions and answer all questions in
complete detail.
- Please print or type all
information. Illegible information will delay underwriting and
processing of your coverage.
- Each family member
requesting coverage must be listed on the Application. All questions on
the Application apply to all applicants requesting coverage. Answer each
and every question, as it pertains to each applicant listed on the
Application. All members of a family must choose the same Deductible.
- Each section of the
application must be completed in full. Any question where a
"YES" was marked must be described in detail in Section 3.
Information in Section 3 must include the applicant's name, physician's
name, address and phone number, address of treating facility, diagnosis,
prognosis, and course of treatment. If necessary, use an additional
sheet of paper to describe the condition(s) and attach it to the
Application when submitted to SRI.
- The Premiums listed are
annual premiums and can be paid by check, money order, VISA®,
MasterCard®, Diners Club®, American Express®, or Discover®. Due to the
inconsistent reliability of international mail, monthly, quarterly and
semi-annual payments can only be made by using a credit card or ACH
payment. Monthly, quarterly and semi-annual payment modes are only
accepted with preauthorization to debit your credit card or checking
account on the due date of your premium installment.
- Once SRI underwrites your
application and determines that coverage should be issued, we will send
you an ID Card and a Certificate of Coverage by mail. The Certificate of
Coverage contains the full program wording and definitions. This package
will also include details concerning procedures for claims submission
and the importance of SRI's pre-notification
procedures.
Section 1. Applicant Information
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Applicant's Name
(Last,
First, Middle, Maiden)
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Sex
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Relationship
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Date of Birth
(Mo/Day/Year)
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Citizenship
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Height
Feet/Inches
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Weight
lbs
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Premium
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Primary
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Spouse
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Child
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Child
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Child
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Total Premium:
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Address of Residence:
Must be outside the United States(street, city,
state, postal code, country)
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Forwarding / Convenience Address:
(street, city, state, postal code, country)
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Home Phone Number:
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Business Phone Number:
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Fax:
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E-Mail:
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Occupation of Primary Insured:
(If retired, previous occupation(s))
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Name of Employer:
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Duties of Occupation:
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Occupation of Spouse:
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Family Physician's Name (Required):
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Address of Family Physician:
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Yes
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No
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1. Do you understand this is an international program and
not U.S. health
insurance?
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2. Do you understand that if you are a U.S. Citizen you are
unable to be in the U.S. longer than 6 months during any given policy year?
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3. If you are a non-U.S. Citizen do you require coverage for
more than 6 months in the United States?
Please enter length of time and how long you require coverage below.
Length of time per year outside the United
States:______________________
How long do you require coverage under Reside?______________________
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4. Are you or any listed dependents currently in the United states?, If yes, enter
departure date below.
When do you plan to depart the United
States: ______ / ______ / ______
(month/day/year)
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5. Are any listed dependents who are age 19, 20, 21, 22 and
23 full time students?(if yes, please list schools and locations)
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Section 2. Health History Questions for Applicants
In order for your Application to be processed successfully, each question
must be answered truthfully. Any answers to "yes" questions must be
explained in Section 3 Health History Details. In addition, answers to
"yes" questions require an Attending Physicians Statement (APS)
dated within the past 90 days containing detailed information and medical
records. All questions for all applicants must be answered and sufficient
medical data reported in order for SRI to underwrite your application.
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Within the past ten (10) years, have you or any applicant
sought treatment or been advised to seek treatment for, been medically
advised, referred, counseled, treated, had surgery, diagnosed or currently
taking prescription medicine for: (Please 'check' all that apply and state
in detail in Section 3. Health History Details.)
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Yes
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No
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1. Digestive system diseases or disorders (including, but
not limited to: gastritis, ulcers, esophageal regurgitation, hemorrhoids,
colon or rectum disorders)?
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2. Cardiovascular and/or circulatory diseases or disorders
(including, but not limited to: elevated blood pressure, hypertension,
elevated cholesterol, heart attack, angina, chest pains, arteriosclerosis,
coronary insufficiency, thrombosis, phlebitis, vascular afflictions,
rheumatic fever, heart murmur)? If "Yes" attach Attending
Physicians Statement (APS) and current blood pressure reading, dated within
the past 90 days describing the cardiovascular and/or circulatory
condition.
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3. Respiratory diseases or disorders (including, but not
limited to: chronic cough, bronchial asthma, bronchitis, tuberculosis, lung
disorders, emphysema, respiratory insufficiency, pleurisy pneumonia)?
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4. Diseases or disorders of the eyes, nose, ears and throat
(including, but not limited to: nasal septum deviation, chronic sinusitis,
cataracts, glaucoma, allergies or hay fever)?
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5. Sexually transmitted diseases or immune deficiency
disorder (AIDS / ARC), tested positive for HIV or any related illness?
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6. Diseases or disorders of the Pancreas, Liver, Gall
Bladder or endocrine disorders (including, but not limited to: obesity,
pituitary or lymph glands, thyroid or metabolic disorders)?
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7. Diabetes? (If "Yes", complete the following)
nbsp;a) Diabetic Type: ____ I
or ____ II
b) Date Diagnosed: ____ / ____ / ____
c) Medications: Type: _____________________ Dosage:
_______________________
d) Controlled by diet only?: ____ Yes or ____ No
e) Date of last HbA1c Test: _____ / ____ / ____ HbA1c
Results (1-10): ____________
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8. Diseases or disorders of the mental and nervous system
(including, but not limited to: mental retardation, psychosis, mental or behavioral
disorders, Down Syndrome or other chromosome disorders, depression,
anxiety, chronic fatigue, eating disorders)?
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9. Neurological disorders (including but not limited to:
multiple sclerosis (MS), muscular dystrophy, Lou Gehrig's
disease (ALS), Parkinson's disease, paralysis, epilepsy, convulsions,
seizures, migraines, chronic headaches, stroke, or transient ischemic
attacks?
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10. Addictive diseases or disorder (including, but not
limited to: alcoholism, chemical or drug abuse or additiction
or has any applicant used illegal drugs or used prescription medication,
other than as prescribed)?
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11. Kidney or urinary tract system diseases or disorders
(including, but not limited to: kidney or bladder stones and infections)?
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12. Cell or blood diseases or disorders (including, but not
limited to: cancer, tumors, cysts, polyps or other growths of the skin or
internal organs, hepatitis, leukemia or Kaposi's sarcoma)?
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13. Muscular or skeletal diseases or disorders and
inflammation (including, but not limited to: scoliosis, arthritis,
rheumatism, gout, tendonitis, joint or vertebrae disorders, osteoporosis)?
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14. Have you or any applicant consulted a therapist,
physician, chiropractor, psychologist, or health care practitioner for medical
advise, medical treatment and/or preventative care? Or have you or any
applicant been hospitalized or undergone medical studies including but not
limited to diagnostic tests, x-rays, electrocardiograms, radiology or blood
work?
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15. For male applicants, diseases or disorders of the
reproductive system (including but not limited to prostate or elevated PSA
level)?
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16. For female applicants, diseases or disorders of the
reproductive system (including but not limited to vaginal bleeding,
fibroids, nodules , fallopian tubes, ovaries or uterus)?
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17. For female applicants, are you currently pregnant or had
a complicated pregnancy or delivery? If currently pregnant, when is the
expected due date? ___________________
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18. For female applicants, diseases or disorders of the
breasts (including but not limited to cysts, nodules, calcifications or
abnormal mammogram)?
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19. Have you or any applicant ever been rejected, ridered, cancelled, or had premium increased for any
Health, Life or Disability Policy?
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20. Are you or any applicant currently hospitalized,
disabled or unable to perform normal activities?
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21. Any Congenital defect, physical disorder or deformity,
or developmental problems not listed above?
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22. In the last 12 months, have you or any applicant used
any form of tobacco?
If "Yes" what form of tobacco? _________ Quantity: _________ How
often: _________
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23. Have you or any applicant recently experienced any
signs, indications, symptoms, diagnosis or treatment that would cause you
to believe that you currently have a new medical conditions?
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Section 3. Health History Detail for Applicants
List details for all "YES" answers to the Section 2 health
history questions (use additional paper, if necessary). Incomplete answers
may delay processing or result in denial of application.
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Name of Person
and Question #
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Condition /
Diagnosis, Treatment Medical Prescribed and Results of Treatment
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Dates
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Physician /
Clinic Address and Telephone #
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Information about prior / other coverage
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Yes
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No
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1. Have you been covered by another medical plan at any time
during the past year?
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2. Will you be covered under any other medical plan
(individual or group) while you are covered under this plan?
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For all "YES" answers, please provide the
following information. If more than one situation applies, attach a
separate piece of paper to describe each situation.
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Name of Insureds: Policy Number: Type of Plan: Spouse's employer group plan Other group plan Individual plan Insurance Company: Phone: Effective Date: Termination Date: Reason for termination: Left employment Employer Canceled plan Non-Renewal |
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Section 4. Declaration and Enrollment Request / Authorization to
Release Medical Information: I hereby apply for the Reside Worldwide
program and for the insurance provided by Certain Underwriters at Lloyds, London
(the "Underwriter"). I hereby subscribe to the Global International
Trust and enroll in the group coverage for which I am eligible under the
group contract issued by Certain Underwriters at Lloyd's, London.
I represent that I have read the completed application and that all my
answers and statements on this Application and any attachments hereto is
complete and true to the best of my knowledge and belief. I understand that
my qualification for insurance is based upon my answers and statements herein
and that this information may be verified by Specialty Risk International,
Inc. (the "Administrator"). I understand that no one has the
authority to exclude or direct me to exclude any information sought by this
form. I understand that the Administrator will rely on all information on
this Application in determining whether or not to issue coverage and that any
incorrect or incomplete information may result in a claim denial or loss of
coverage.
I understand that benefits may be limited or excluded for conditions for
which any insured person has received any medical diagnosis or treatment, or
taken any medication, or realized the manifestation of a condition before his
or her effective date, according to the pre-existing conditions limitations
provisions of the plan.
I AUTHORIZE any physician, medical practitioner, hospital, clinic, other
medical or medically-related facility, the Medical Information Bureau, Inc.
(MIB, Inc.), consumer reporting agency, insurance or reinsuring company, or
employer having certain information about me or my dependents to give
Specialty Risk International, Inc. or its legal representative, any and all
such information. The nature of the information authorized to be disclosed
includes, but is not limited to, information about: physical condition(s),
health history(ies), avocation(s), age(s),
occupation(s), and personal characteristics. This authorization includes
information about drugs, alcoholism, mental illness, or communicable
diseases.
I UNDERSTAND the information obtained by use of this Authorization will be
used by the Administrator to determine eligibility for benefits. I ALSO
AUTHORIZE the Administrator to release any information obtained to reinsuring
companies, Medical Information Bureau, Inc., or other persons or
organizations performing business or legal services in connection with my
application, claim, or as may be otherwise lawfully required, or as I may
further authorize.
I UNDERSTAND that as a resident of a foreign jurisdiction, I may be
subject to foreign laws with respect to the type and form of coverage in
which I am enrolling. I also understand and agree that responsibility for
complying with those foreign laws rests solely on me.
I UNDERSTAND that no coverage is effective until I am notified in writing
by the Administrator and advised of the official Effective Date. I also
UNDERSTAND that if I am not accepted for coverage by the Administrator, the
sole obligation of the Administrator and the Underwriter is to return the
premium. I also UNDERSTAND that if I am a United States
citizen, coverage in the United States
is limited to 6 months during any one 12 month policy period. I also
UNDERSTAND that Lloyds operates as an unauthorized insurer in most US states
and that claims may not be made against any state guarantee fund. I
UNDERSTAND and AGREE that this program is issued outside the United
States and that the program does not comply with any US
state insurance law.
I UNDERSTAND that this program is not, nor does it intend to be, a general
United States
health insurance policy. I ALSO
UNDERSTAND any person who, with intent to defraud or knowing that he or she
is facilitating a fraud against an insurer, submits an enrollment form, or
files a claim containing a false or deceptive statement may be guilty of
insurance fraud.
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SIGNATURE of Applicant or Guardian:
________________________________________ Date:_____________
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SIGNATURE of Applicant's Spouse (if applicable):
________________________________ Date:_____________
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Section 5. Program Specifics
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Please Choose Your Deductible:
$250 $500 $1,000 $2,500 $5,000
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Requested Effective Date: ________ / _______ / _______
(month/day/year)
(Requested Effective Date must be within 60 days of application date. If
accepted, official Effective Date will be advised by SRI)
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For the AD&D benefit, the Primary Insured shall be the
beneficiary of the certificate. If the benefit is utilized for the Primary
Insured, his/her estate shall be the beneficiary. If this is not
acceptable, please list the beneficiary:
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Premium Calculation and Payment
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X
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=
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+
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$20.00
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Annual Premium
for all applicants
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Installment
Factor(from below)
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Total Premium
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Application Fee
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Total Initial
Payment
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Installment Factor: Annual =
1.00 Semi-Annual = 0.55 Quarterly =
0.28 Monthly = 0.10
Important: Checks and Money Orders accepted for Annual Premium Only from U.S.
banks
Method of Payment
Check Money Order Visa MasterCard Discover / Novus American Express Diners Club
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Card Number:
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Expiration Date:
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Name as it appears on the Card:
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Daytime Phone:
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Signature (Required):
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Alternate Phone Number:
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Billing Address:
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All premium payments must be made in U.S. dollars. Checks must be issued
from a U.S. bank and made payable to "SRI". If paying by credit
card, I authorize SRI to debit my credit card 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 SRI to debit my credit card
periodically as payment installments become due. This authorization will
remain in effect until revoked by me in writing, and until SRI actually
receives notice. Coverage purchased by credit card is subject to validation
and acceptance by credit card company. *For any installment payment other
than annual, I pre-authorize SRI to debit my credit card for the proper
installment amount on the due date of the installment.
_____________________________________________
(Sign here for Pre-Authorization of Installment Premiums)
Check or money order should be made payable to SRI. All payments must be
made in U.S. dollars, from a U.S. Bank, and submitted at the time application
for coverage is made.
Agent Information
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Agent Name: Good Neighbor Insurance
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SRI Agent #: 1586
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Address (City/State/Zip/Country):
620 S. Winthrop St.
Gilbert, AZ 85296, USA
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Phone (incl area code)
480/813-9100; Toll Free: 866/636-9100
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Fax (incl area code)
480/813-9930
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E-Mail: Info@gninsurance.com
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Agent Certification:
I am not aware of any other information which may have a bearing on the
insurability of anyone to be covered and have not altered any responses
recorded on this application nor any supplement to the application. I have
not advised the Applicant to withhold any information regarding the answers
to the questions and have advised the Applicant to review the application and
the answers recorded to confirm completeness and accuracy.
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SIGNATURE of Agent:
________________________________________ Date:_____________
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Security
Certain Underwriters at Lloyd's, London; Rated A- "Excellent" by
A.M. Best and A+ "Strong" by Standard and Poors.
Please mail or fax to
Good Neighbor Insurance, Inc (GNI)
620 S Winthrop St.
Gilbert, AZ 85296, USA
Fax: 480/813-9930
Important Information
It is important to note that Reside Worldwide is a program for
international citizens and Lloyd's is an international entity. Thus, Lloyd's operates
as an unauthorized insurer in most U.S.
states. Coverage and benefits under Reside Worldwide are not regulated by any
U.S. state
insurance department.
The information concerning Reside Worldwide is not intended to be an offer
to sell Reside Worldwide or a solicitation by Specialty Risk International,
Inc or Lloyd's, London in any jurisdiction where such an
action would be unlawful or in which SRI or Lloyd's, London
is not qualified to do so. Reside Worldwide may not be available in all
situations or jurisdictions. For U.S.
citizens, Reside Worldwide is intended for persons living or traveling
outside the United States.
Copyright 1998 - 2005 by Specialty Risk International, Inc.
Reside® is a registered trademark of Specialty Risk International, Inc.
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