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International Citizens Application for Insurance

How do I apply? It's easy. Just print and complete the following application.
Mail the completed form, along with your payment, to:

        MultiNational Underwriters, Inc.
        107 S. Pennsylvania Street, Suite 402
        Indianapolis, IN 46204

If paying by credit card, you may fax your application to 317.262.2140
or E-mail it to 1world@1worldinsurance.com.

Important Instructions For All Applicants

1. Review your answers to each question on this Application for accuracy. Unanswered questions or incomplete information will delay processing.

2. All Applications must be signed and dated. Full details, including treatment dates, name, address and telephone number of attending physician, diagnosis, prognosis and present course of treatment must be provided for all yes answers in Part 2.

3. All family members must apply for the same plan and Deductible.

4. Annual premiums may be paid by check, money order or credit card authorization. MultiNational Underwriters, Inc. will not accept checks or money orders for quarterly or semi-annual payment modes. These payment modes are only accepted with pre-authorization to debit your credit card on the due date of your premium.

5. If you are a US citizen, or if you are in the US now, you must provide your anticipated date of departure from the US and your anticipated length of residence outside the US.

6. If you would like to have your Certificate overnighted to you after approval, add an additional $15 to your premium.

Part One

Deductibles Term Life

Platinum ___ $250       ___ $1,000
___ $500       ___ $2,500
___ Yes       ___ No

Premier ___ $250       ___ $1,000
___ $500       ___ $2,500
___ Yes    ___ No

Risk Share ___ $1,000    ___ $5,000
___ $2,500
___ Yes    ___ No

Requested Effective Date (must be within 30 days of signature):

Premium (from Part 6):
     $

Note: Include only the family members applying for coverage. Attach additional sheets if necessary.
Please print your name as you would like it to appear on your Identification Card.

Name (First name, middle initial, last name)
Country of Citizenship Date of Birth Sex Height Weight

1. Applicant:
    Citizenship:

2. Spouse:
    Citizenship:

Dependent Children:

3. Name:
    Citizenship:

4. Name:
    Citizenship:

5. Name:
    Citizenship:

Address of residence outside the US

Street Address: City: State Postal Code:

Country:

Mail forwarding address if different from above

Street Address: City: State Postal Code:

Country:

If you or any family member are a US citizen or if you are in the US now, the following information is required:

Date of departure from US: Length of Residence outside of US:

Your Occupation: Employer Name:

Date Hired: Prior Employment
(if within 2 years):

Part Two

Please answer all questions for all members of the family included in this Application. In Part 3, provide details to all "Yes" answers.

Yes No

1. Have you ever had an application for health or life insurance voided, declined cancelled, rescinded or modified (including medical exclusion riders)?

2. In the last 12 months, have you used tobacco in any form?

3. In the last 12 months, have you experienced a weight change of 15 pounds or more?

4. In the last 5 years, have you had any indication, diagnosis or treatment of an alcohol or drug dependency, problem or abuse or any alcohol or drug related arrest?

5. In the last 5 years, have you consumed alcoholic beverages in the excess of 14 drinks per week?

6. Are you pregnant or do you have an adoption pending?

7. Do you (not including dependent children) read, write, speak and understand English? If no, what is your primary language?

8. In the last 12 months, have you taken medication or received medical advice or treatment of any kind?

Within the last 10 years, have you had any indication, signs, symptoms, diagnosis or treatment of any disease or disorder of: Yes No

9. Gallbladder?

10. Pancreas or liver?

11. Joints or spine?

12. Kidney?

13. Eyes, ears or nose?

14. Mouth, throat or jaw?

Within the last 10 years, have you had any indication, signs, symptoms, diagnosis or treatment of: Yes No

15. High blood pressure?

16. Chest pain?

17. Headaches?

18. Paralysis?

19. Arthritis?

20. Convulsions or epilepsy?

21. Elevated cholesterol?

22. Sexually transmitted disease?

23. Cancer?

24. Diabetes or sugar in the blood or urine?

25. Stroke?

26. Acquired Immune Deficiency Syndrome (AIDS) or any HIV-related disease or illness?

27. Tumor, cyst, polyp, lump or growth of any kind? In the last 10 years, have you:

28. Had a complicated pregnancy or delivery?

29. Tested positive for antibodies to the HIV virus?

30. Been hospital confined, had surgery or discussed surgery?

31. Consulted a mental health professional?

In the last 10 years, have you had any indications, signs, symptoms, diagnosis or treatment of any disease, disorder, or abnormality of the: Yes No

32. Heart or circulatory system?

33. Nervous system?

34. Digestive system?

35. Muscular or skeletal system?

36. Respiratory system?

37. Male or female reproductive system?

38. Urinary system?

39. Thyroid, breast or other glands?

40. In the last 10 years, have you had any signs, indication, symptoms, diagnosis or treatment of any other disorder, disease, injury or adverse or abnormal test results?

Part 3

For any question answered "Yes", please state the name of the family member (using the corresponding number from Part 1). Provide details of the condition including: treatment dates, name, address and telephone number of the treating physician, diagnosis, prognosis and present course of treatment. Attach additional pages if necessary. Additional information may be requested.

Part 4

For each family member applying for Term Life Insurance, please complete the following:

Basic Life Supplemental Life

Applicant:
Beneficiary:
____ Yes
____ No
____ Yes
____ No

Spouse:
Beneficiary:
____ Yes
____ No
____ Yes
____ No

Dependent Child:
Beneficiary:
____ Yes
____ No
Not available

Dependent Child:
Beneficiary:
____ Yes
____ No
Not available

Dependent Child:
Beneficiary:
____ Yes
____ No
Not available

Provide full address for each Beneficiary listed above (attach additional sheets if necessary):

I understand Term Life Insurance will not become effective until the date of my departure from the US.
____________ (Applicant initial here) ____________ ( Spouse initial here)
____________ (Initial here for Dependent Children)

Part 5

I hereby apply for membership in the Atlas/International Citizen Group Insurance Trust, Hamilton, Bermuda, and for the insurance provided by Certain Underwriters at Lloyds, London. I have personally completed this Application. I represent that the answers and statements on this Application are true, complete and correctly recorded. I understand that any misrepresentation contained herein will void my insurance and all claims will be forfeited. I understand that no coverage is effective until I am notified in writing by MultiNational Underwriters, Inc. I understand that if this Application is not accepted, the sole obligation of the MultiNational Underwriters, Inc. is to return the premium to me. The undersigned authorizes any doctor, medical practitioner, hospital, clinic, health facility, pharmacy, government agency, insurance agency, insurance company, group policyholder or insurance or benefit administrator or any other entity having information as to the care, advice, treatment, diagnosis or physical or mental condition of any family member listed on this Application to release said information to MultiNational Underwriters, Inc.

Signature of Applicant or Guardian:

Signature of Spouse:

Date of Signature:

Date of Signature:

Part 6

PREMIUM CALCULATION:
Applications without premium will not be processed. We will not accept checks or money orders for quarterly or semi-annual payment modes. For quarterly or semi-annual payment modes we will only accept a pre-authorized credit card. Either checks or credit cards may be used for annual payment modes. Please make all checks payable to: MULTINATIONAL UNDERWRITERS, INC.

Medical:
Enter the Annual Premium for each family member from the Rate Table for the plan and Deductible selected.

Applicant: $ ________________
Spouse: $ ________________
1st Child: $ ________________
2nd Child: $ ________________
3rd Child: $ ________________
Subtotal A: $ ________________

Life:
Enter the Annual Premium for each family member from the Optional Term Life and AD&D Insurance Rate Table:

Basic
Supplemental
Total

Applicant: $ ____________
$ ____________
$ ____________

Spouse: $ ____________
$ ____________
$ ____________

Child Life:
$100 X ____________
(# of children) = $ ____________

Subtotal B: $ ____________

Total Premium: (Subtotal A + B) $ ____________

Modal Factor* $ ____________

Non-refundable Policy Fee (add $100 for Risk Share Applications only) $ ____________

Total due: $ ____________

*Modal Factors: Annual 1.00 Semi-Annual .55 Quarterly .28

Method of Payment:
Check or Money Order MasterCard VISA American Express

Credit Card #

Name as it appears on card:

Signature:

Expiration Date:

Billing Address:

Daytime Phone #

Agent #99157-00001

Check or Money Order should be payable to MultiNational Underwriters, Inc. All payments must be made in US dollars. If paying by credit card, I authorize MultiNational Underwriters, Inc. to debit my Visa/MasterCard/American Express account for the total amount due. If I have elected Semi-Annual or Quarterly payment modes, I hereby request and authorize MultiNational Underwriters, Inc. to debit my credit card account for the proper installment amounts on the due dates of the installments. This authorization will remain in effect until revoked by me in writing. Coverage purchased by credit card is subject to validation and acceptance by the credit card company.

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Street Address:	City:	State	Postal Code:

Country:
Mail forwarding address if different from above

Your Occupation:	Employer Name:
Date Hired:	Prior Employment (if within 2 years):

	Yes	No
1. Have you ever had an application for health or life insurance voided, declined cancelled, rescinded or modified (including medical exclusion riders)?
2. In the last 12 months, have you used tobacco in any form?
3. In the last 12 months, have you experienced a weight change of 15 pounds or more?
4. In the last 5 years, have you had any indication, diagnosis or treatment of an alcohol or drug dependency, problem or abuse or any alcohol or drug related arrest?
5. In the last 5 years, have you consumed alcoholic beverages in the excess of 14 drinks per week?
6. Are you pregnant or do you have an adoption pending?
7. Do you (not including dependent children) read, write, speak and understand English? If no, what is your primary language?
8. In the last 12 months, have you taken medication or received medical advice or treatment of any kind?

Within the last 10 years, have you had any indication, signs, symptoms, diagnosis or treatment of any disease or disorder of:	Yes	No
9. Gallbladder?
10. Pancreas or liver?
11. Joints or spine?
12. Kidney?
13. Eyes, ears or nose?
14. Mouth, throat or jaw?

Within the last 10 years, have you had any indication, signs, symptoms, diagnosis or treatment of:	Yes	No
15. High blood pressure?
16. Chest pain?
17. Headaches?
18. Paralysis?
19. Arthritis?
20. Convulsions or epilepsy?
21. Elevated cholesterol?
22. Sexually transmitted disease?
23. Cancer?
24. Diabetes or sugar in the blood or urine?
25. Stroke?
26. Acquired Immune Deficiency Syndrome (AIDS) or any HIV-related disease or illness?
27. Tumor, cyst, polyp, lump or growth of any kind? In the last 10 years, have you:
28. Had a complicated pregnancy or delivery?
29. Tested positive for antibodies to the HIV virus?
30. Been hospital confined, had surgery or discussed surgery?
31. Consulted a mental health professional?

In the last 10 years, have you had any indications, signs, symptoms, diagnosis or treatment of any disease, disorder, or abnormality of the:	Yes	No
32. Heart or circulatory system?
33. Nervous system?
34. Digestive system?
35. Muscular or skeletal system?
36. Respiratory system?
37. Male or female reproductive system?
38. Urinary system?
39. Thyroid, breast or other glands?
40. In the last 10 years, have you had any signs, indication, symptoms, diagnosis or treatment of any other disorder, disease, injury or adverse or abnormal test results?

		Basic		Supplemental		Total
	Applicant:	$ ____________		$ ____________		$ ____________
	Spouse:	$ ____________		$ ____________		$ ____________
	Child Life:		$100	X ____________ (# of children)	=	$ ____________
	Subtotal B:					$ ____________
	Total Premium: (Subtotal A + B)					$ ____________
	Modal Factor*					$ ____________
	Non-refundable Policy Fee (add $100 for Risk Share Applications only)					$ ____________
	Total due:					$ ____________
*Modal Factors: Annual 1.00 Semi-Annual .55 Quarterly .28