UNDERWRITTEN BY CORMORANT INTERNATIONAL LIMITED,

If child-only coverage is being requested, the child is the primary applicant and a separate application must be completed for each child.

Requested Effective Date:

NOTE: the 29, 30 and 31 of the month are not

eligible as effective dates. Application is valid within 60 days from the signature date.

MO.                                     DAY                          YR.

Birth Date:                     Age:                   Place of Birth:                      (Country)

Height:                                                     Weight:             

ft.      in.                                                          lbs.

Social Security Number:

First Middle                                                    Last

Guardian’s Name: (with whom the child resides):

 Relationship to Child

Social Security Number:

GUARDIAN INFORMATION (For Applicants under 18 years of age):

CITIZENSHIP INFORMATION

Primary Applicant’s Name:

F i r s t                                       M i d d l e                                  L a st

SECTION 1: GENERAL INFORMATION

Authorization Code:

( If Coverage  was  r e q u e s t e d)

Please check if this application is for:

 @New Applicant                @Add Dependent     @Plan Change        @Reapply

Sex: @Male                         @Female

Marital Status:@Single        @Married               @Divorced               @Widowed

Name S t r e e t                                                          

C i t y                                                                           S t a t e                        Z i p

Name and Billing Address:

 

Home Phone Number:

 Phone Number during regular business hours:

 Occupation:

 ( Position and Type of Business)

BILLING INFORMATION If different from Applicant’s Home Address (Please send bills to):

Are the following Applicants to be insured Cyprus citizens?

Primary applicant: @Yes      @No*

Spouse:  @Yes    @No*

Dependent(s):        @Yes       @No*

*If anyone answered “No,” to the above question, please indicate if he or she has been a permanent legal resident of Cyprus for the last two years?

Primary applicant: @Yes       @No**

Spouse:  @Yes    @No**

Dependent(s):         @Yes       @No**

**If “No,” coverage cannot be granted for that applicant.

Does the payor want to include other family members on one billing statement? @Yes  @No

If “Yes,” the Family Billing Statement Form needs to be completed, dated, signed and submitted with the application.

CORMORANT INTERNATIONAL  INSURANCE COMPANY 

Have you and/or any dependent to be covered previously applied for insurance with Cormorant International Insurance Company?

 @Yes           @No

@Monthly Automatic Pay - One month premium required (Complete Section 4)

 @Monthly Billing* - One month premium required

 @Quarterly Billing* - Three months premium required

*£8 billing fee per month or quarter

Subsequent Payment Schedule: Initial Payment Method:

One month/quarter premium required

(Complete Section 4): @ Credit card (including Check/Debit cards)  @Check

Total Payment Submitted:

£ /Monthly + One-time, non refundable Application Fee = £ Total Payment submitted

£/Quarterly + One-time, non refundable Application Fee = £ Total Payment submitted

Best Time To Call: Primary Applicant’s Home Address:

S t r e e t                                                             

C i t y

S t a t e                                 Z i p

 C o u n t r y                                 a.m. p.m.

FOR OFFICE USE ONLY

Email:

Account No.16420

Sales Representative

 

DEPENDENT INFORMATION (Complete only for dependents to be covered under this plan.)

Spouse’s Name: Sex:

 @ Male Spouse’s Social Security Number:

@ Female

F i r s t                                              M i d d l e                                      L a st

SECTION 1: GENERAL INFORMATION (continued)

Birth Date:                            Age:                            Height:                             Weight:

Spouse’s Occupation: (Position and Type of Business)

OTHER HEALTH COVERAGE

Do you or any dependents to be insured have any major medical health insurance coverage currently in force?   @Yes*   @No

*If “Yes,” will the insurance coverage applied for be used to replace this existing coverage?     @Ye s               @N o

(If “Yes,” a replacement form may be required in your state. Consult your agent. If “No,” coverage cannot be issued.) Were you or your dependents covered under any other Health Insurance plan in the last 18 months? @Yes*         @No

*If “Yes,” what type of coverage was your or your dependents last plan? @Employer Based Group @I n d i v i d u a l @C O B R A @O t h e r

If you currently have a major medical plan in force or had coverage in the last 18 months complete the following:

Name of covered individual(s):

Carrier Name:

Telephone number:

Policy Number or Group Number:

Effective Date of Policy:

Termination Date of Policy:

IMPORTANT: DO NOT cancel any existing health coverage until written notification of your acceptance by Cormorant.

PLAN INFORMATION

PLAN OPTIONS (Choose one of the three plans)

Who is to be insured?

 l Applicant (only)

l Applicant/Spouse

l Applicant/Child(ren)

 l Family

Managed Indemnity Plan: @70/30 of the next £8,000 __________deductible @80/20 of the next £5,000 __________deductible @100% £__________deductible

(£1,000, £1,500, £2,500, £5,000, £8,000) (£250, £500, £1,000, £1,500, £2,500, £5,000, £8,000) (£1,000, £1,500, £2,500, £5,000, £8 ,000)

“Any Doc” PPO Plan: @70/30 of the next £8,000 __________deductible @80/20 of the next £5,000 __________deductible @100%£ __________deductible

(£1,000, £1,500, £2,500, £5,000, £8,000) (£250, £500, £1,000, £1,500, £2,500, £5,000,£8 ,000) (£1,000, £1,500, £2,500, £5,000,£8 ,000)

Select PPO Plan: @70/30 of the next £8,000 __________deductible @80/20 of the next £5,000 __________deductible @100% £__________deductible

(£1,000, £1,500, £2,500, £5,000, £8,000) (£250, £500, £1,000, £1,500, £2,500, £5,000, £8,000) (£1,000, £1,500, £2,500 £ 5,000, £8,000)

Would you like the

Plus Option?  @Yes        @N o

Would you like the Term

Life Insurance Option?*        @Yes              @N o

If Term Life is selected, Beneficiary Name: Relationship to You:

BENEFIT OPTIONS *The Term Life Insurance Option is not available in Northern Cyprus.

Name of Dependent Child(ren):

Social Security Number:

 Birth Date:                           Sex:                HT.         (ft. & in.)                         WT. (lbs.)

Accurate Readings Required

TION 2: HEALTH AND OCCUPATION QUESTIONS

HEALTH QUESTIONS

For this insurance to be issued, the following health questions must be answered fully and truthfully to the best of your knowledge and belief and all of the health information must be provided, and Cormorant International Insurance Company must approve this application. No one may change this requirement in any way. If any information on any form is misstated or omitted, coverage may later be rescinded. Rescission voids coverage from the effective date,and any premiums already paid will be refunded, minus any claims already paid. No payments will be made for any claims submitted, whether or not the treatment was related to the condition that was omitted or misstated.

PLEASE DO NOT MARK OVER OR STRIKE OUT ANY SIGNATURE, DATE OR HEALTH QUESTION INFORMATION.(Any changes, corrections or alterations must be initialed and dated by the primary applicant.)

1.PREGNANCY   @YES*     @NO

Are you, your spouse or any dependent, whether to be covered or not, now pregnant or an expectant parent or have an adoption pending?

(If “YES,” this coverage cannot be provided.)

2.GENERAL HEALTH            @YES*                         @NO

a. Within the last 10 years, has anyone to be insured been counseled or advised that they have or may have had any disease, disorder, impairment, deformity, familial or congenital abnormality, injury or any chronic or untreatable condition either active or in remission?   @YES*                          @NO

b. Does anyone to be insured have a prosthetic device or implant (including breast implants)?                    @YES                           @NO

c. Have you or any dependent to be insured used any type of tobacco product in the past 12 months? If “Yes,” check all who apply:

 @Applicant        @Spouse  @Dependent(s)   @YES* @NO

d. Have you or any of your dependents been prescribed any medications in the last 12 months?

3.SPECIFIC HEALTH CONDITIONS

Within the last 10 years, have you or any dependent(s) to be insured ever been treated for, had symptoms of, or been advised or counseled that they have or may have had: (Y=Yes     and     N=No)

4.RECENT MEDICAL TREATMENT

a. Within the past 24 months, have you or any dependent(s) to be insured undergone or been advised or recommended for: (Y=Yes    and       N=No)

3

Y* N l  l Heart condition, (including chest pains or a heart murmur), stroke, high blood pressure or other circulatory disorder  l  l  Blood disorder  l  l Diabetes  l l Cancer, tumor or cyst  l  l Liver, kidney, genital or urinary tract disorder  l  l Any disease or disorder of the reproductive system including infertility, complications of pregnancy, sexual dysfunction or sexually transmitted disease(s)  l  l Elevated Cholesterol  l l Neurological disorders or condition Y*   N   l  l Seizures or other nervous system disorder  l  l Arthritis, fibromyalgia, gout, back, spine, joint or other musculoskeletal system disorder  l  l Chronic Fatigue Syndrome  l  l Digestive system disorder  l  l Asthma, allergies or other respiratory disorder  l  l Eye, ear or skin disorders  l  l Alcohol, substance or drug abuse or dependence. Emotional, psychological, psychiatric or nervous condition or disorder  l  l Thyroid disorder Y*  N  l  l Lab work or tests l l Hospitalization l  l Surgery or surgical consultation l  l Treatment for any conditions)  Y*  N  l  l Psychological or marital counseling  l  l Physical, occupational, or disability therapy  l  l Second opinion from another physician *Coverage cannot be granted over the phone. Please mail in your application for processing.

 (continued)

Bartenders, crop dusting,Hazardous materials ,Inter-state trucking,Mining,Modeling,Motorized vehicle racing,Musician,Off-shore drilling,Police,Professional fire fighting,Professional sports or athletics,Roofing

If “Yes”, please provide the name(s) of each person and their occupation/avocation.

Name:                                            Occupation/Avocation:

Name:                                            Occupation/Avocation:

@YES* @NO

 b. Are you or any dependent(s) to be insured scheduled for or awaiting the results of any tests, biopsies, procedures or lab work? @YES*     @NO 5.IMMUNE SYSTEM DISORDER

Have you or any dependent(s) to be insured ever been treated for or diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), diseases associated with AIDS or other immune system disorders, or ever tested positive for antibodies to the Human Immunodeficiency Virus (HIV)?  @YES*   @NO 6.OCCUPATION/AVOCATION QUESTION

Do you or any dependent(s) to be insured participate in or work in any of the following occupations/avocations?

7.FOR APPLICANTS AGE 50 OR OLDER

a. General

@YES*  @NO    Have you or any dependent over 50 had a physical within the last 24 months?

b. Male Applicants Only - PSA Results:

What was the date of your most recent PSA (Prostate Specific Antigen) test? What was the exact level/reading?

c. Female Applicants Only - PAP/Mammogram Results:

What was the date of your most recent mammogram?

Results normal?   @Yes       @No

What was the date of your most recent pap smear?

Results normal?   @Yes       @No

Coverage cannot be granted over the phone. Please mail in your application for processing.

SECTION 3 : ADITIONAL HEAKTH QUESTION INFORMATIONECTION 3: ADDITIONAL HEALTH QUESTION INFORMATION

To be completed if the applicant or any dependent(s) answered “Yes” to  ny questions in Section 2. If more space is needed attach a separate sheet, each separate sheet must be signed and dated by the primary  applicant.

Please give month and year when providing dates. Also, please give specifics when listing conditions, (Ex. Broken left leg.)

Question. No.:

Applicant’s Name:

Diagnosis/Condition:

Onset Date:                                                            Date Last Treated:

Length of Treatment:

Medication(s), including over the counter (please list med/dosage and date last taken):

Name of Test/Surgery/Date/Results:

Is the condition still present? If not, date of recovery:

Details of Treatment/Treatment pending or scheduled:

Doctor’s name, Address and Phone Number:

Question. No.:

Applicant’s Name:

Diagnosis/Condition:

Onset Date:                                                                  Date Last Treated:

Length of Treatment:

Medication(s), including over the counter (please list med/dosage and date last taken):

Name of Test/Surgery/Date/Results:

Is the condition still present? If not, date of recovery:

Details of Treatment/Treatment pending or scheduled:

Doctor’s name, Address and Phone Number:

SECTION 4: PREMIUM PAYMENT METHOD AND AUTHORISATION AGREEMENT

INITIAL PAYMENT( CREDIT CARD OR CHECK)

Signature of Primary Payor: Date:

Payor Name or Depositor if different (Please print): Relationship to Applicant:

F i r s t                                              M i d d l e                                           L a st

Name of Financial Institution: Address:

Specify type of account: @Checking or @Savings Checking/Savings Account Number:

ABA9 Digit Routing Number (See below or please call your Financial Institution for assistance):

Cormorant International Insurance Company is hereby authorized to present checks drawn on my checking or savings account on the first business day of each month, until this authorization is terminated. I understand that premiums already paid will be refunded to me if my Certificate is not issued. I further authorize the bank named to pay and charge to my account those payments that are drawn on my account by Cormorant international Insurance Company, and I agree that the bank named shall be fully protected in honoring any such payments. The bank’s rights and treatment of each payment shall be the same as if it were signed by me. If any such payment is dishonored, whether with or without cause, I understand that the bank shall not be liable whatsoever, even though such dishonor results in a forfeiture of insurance. The authorizations above remain in effect until the bank is notified of termination by me in writing. To terminate coverage, I will also notify Cormorant International  Insurance Company in writing.

MONTHLY AUTOMATIC PAY PLAN

Initial Payment (Credit Card or Check): PRODUCER PAYMENTS ARE NOT ACCEPTED.

1. For Initial Payment Only: I authorize Cormorant International Insurance Company to bill my account for the initial payment and I agree to pay

the initial payment billed in accordance to my payment selection on this application by checking the following credit card box: @VISA® (including Check/Debit cards*) @Mastercard® (including Check/Debit cards*) @Discover®

* Debit cards must have a Visa or Mastercard logo on the front of the Debit Card.

Card No.:

Expiration Date (MO/YR):

Cardholder’s Name: __________________________________________________________

2. Or, attach your check below for total payment submitted.

C I T Y                                   S TAT E                                  Z I P

DO NOT STAPLE CHECKS TO FORM.

 

SECTION 5 : AGREEMENT AND SIGNATURE

AGREEMENT AND SIGNATURE

1 . TRUE AND COMPLETE: My answers to the questions on this application and any additional information I have provided are true and complete and accurately recorded. I understand that under no circumstances is a producer or company representative allowed to permit me to answer any question inaccurately or untruthfully and I represent that such did not occur. The producer is not authorized to alter any terms of the Certificate. I understand that I may not pay cash or make checks payable to the agent or broker, or leave the payee blank.

2 . PRE-EXISTING CONDITIONS: I understand that eligible expenses for pre-existing conditions may be limited.

3 . EFFECTIVE DATE: Except as provided in the Conditional Receipt, I understand that insurance, if approved, will become effective the day after the confirmed receipt date the application and all required medical and other  information is received by Cormorant and the initial premium is paid in full. Application is valid within 60 days from the signature date.

4 . H E A LTH CARE CERTIFICATION : I understand that a Health Care Certification Program is a part of the Health Plan.This program requires me to have all hospital confinements, outpatient surgeries, and major diagnostic tests Certified. I understand that failure to do so will result in a reduction of my health plan benefits or no benefits paid at all. 

5 . OTHER COVERAGE: I understand that in order to be eligible for this coverage, neither I, nor any dependents to be insured can be covered under any other major medical plan. I hereby attest that no one applying for coverage under the Health Plan will be covered under any other coverage.

6 . PREFERRED PROVIDER ORGANIZATION : I understand if I have selected one of the PPO plan options as part of my Health Plan, then I agree to participate and comply with all requirements of the PPO plan. I understand that I will  maximize my benefits when treatment is received from a participating hospital (and physician, if the Select PPO plan is chosen) and that it is my responsibility to ensure that a PPO hospital (and physician, if the Select PPO plan is chosen)  is near me. I understand this applies not only to myself, but to any dependent to be insured under this health plan.

7 . A P P L I C ATION: I understand that I am applying for membership in the  Cormorant Health Plan Trust and am responsible for ensuring that all premium payments are met. I understand that Cormorant will individually underwrite my  application and that if my application is accepted by Cormorant, a Certificate will be issued to me. I understand that the plan applied for is not an employer-sponsored group health plan, that it will in no way be related to any employer/employee relationship, and it is not offered pursuant to and does not comply with state or federal small employer laws. If premium will be paid from a business/employer account, I hereby certify that no person to be insured under this plan will receive favorable tax treatment of the Cyprus Revenue Code, unless such favorable tax treatment would not make the plan subject to any area or federal small employer laws.

8 . A U T H O R I Z ATION TO RELEASE INFORMAT I O N : I authorize any physician, medical or health care practitioner, hospital, clinic, other medically related facility, insurance company, third party administrator, employer or  consumer reporting agency having information regarding me and all eligible dependents, including information concerning advice, diagnosis, treatment or care of physical, psychiatric, mental or emotional conditions, drug, substance, or  lcohol abuse, illness, and copies of all hospital or medical records, or non-medical information, to give to Cormorant International Insurance Company, its reinsurers, or its legal representatives, and its affiliates, any and all such information. Such information may be used by Cormorant International Insurance Company to determine eligibility for insurance and make claim determinations. This authorization shall remain valid for two years from the date shown below. Anyone who knowingly misrepresents or falsifies such requested information may, upon conviction, be subject to a fine or imprisonment. I acknowledge having received and read the Notice of Information Practice.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

SIGNATURE: PRIMARY APPLICANT:                                                       SPOUSE:

DATED AND SIGNED AT:                                                                         on

City                               State                                               Date

(Parent or Guardian if under 18 years of age)

ADDITIONAL INFORMATION

ADDITIONAL DEPENDENTS

Name of Dependent Child(ren)                Birth Date                 Sex      HT    WT

 

 

ADDITIONAL INSURANCE INFORMATION

 

 

ADDITIONAL HEALTH INFORMATION

Question No:

Applicant's name

Diagnosis/ Condition

Onset Date :                                               Date Last Treated :

Length of Treatment :

Medication(s) including over the counter(please list med/dosage and date last taken):

Name of Test/Surgery/Date/Results

Is the condition still present? If not date of recovery:

Details of Treatment/Treatment pending or scheduled:

Doctors Name,address,and phone number.

 

ADDITIONAL HEALTH  QUESTION INFORMATION

Please give month and year when providing dates. Also, please give specifics when listing conditions, (Ex. Broken left leg.)

Question. No.:

Applicant’s Name:

Diagnosis/Condition:

Onset Date: Date Last Treated:

Length of Treatment:

Medication(s), including over the counter (please list med/dosage and date last taken):

Name of Test/Surgery/Date/Results:

Is the condition still present? If not, date of recovery:

Details of Treatment/Treatment pending or scheduled:

Doctor’s name, Address and Phone Number:

Question. No.:

Applicant’s Name:

Diagnosis/Condition:

Onset Date: Date Last Treated:

Length of Treatment:

Medication(s), including over the counter (please list med/dosage and date last taken):

Name of Test/Surgery/Date/Results:

Is the condition still present? If not, date of recovery:

Details of Treatment/Treatment pending or scheduled:

Doctor’s name, Address and Phone Number:

MEDICAL FREE FORM NOTES