RESIDE Prime Worldwide Medical Plan Web Application

As described in the brochure and documentation, RESIDE Prime Worldwide Medical Plan 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 note that RESIDE Prime limits coverage in the United States to 6 months during any given 12 month policy period. This plan is not intended to cover permanent residents of the United States, please see "Important Information" section at the end of the application.

SECTION 1. APPLICANT INFORMATION:

Applicant's Name (Last, First, Middle, Maiden)	Sex	Relationship	Date of Birth (Mo/Day/Yr)	Birthplace State/Country	Height Feet / Inches	Weight lbs	Premiun
		Primary
		Spouse
		Child
		Child
		Child
Total:

Residence Address: (street, city, state, country, postal code):
Mailing Address: (street, city, state, country, postal code):

Home Phone:	Business Phone:
Fax:	E-Mail Address:

Occupation of Primary Insured:

Occupation of Spouse:

Previous Occupation:

Name of Employer:

Single or Married (please circle)

If you are a US citizen: When do you plan to depart the US? _____ / _____ / _____ (month/day/year)

How long do you plan to reside outside of the US during a given year?

Do you understand that you are unable to be in the U.S. longer than 6 months during any given policy year?

(If you spend more then 6 months in the U.S., this insurance will not be valid)

Do you understand this is an international program and not U.S. health insurance?

How many years do you intend to have this plan?

Are all listed dependents who are age 19, 20, 21, 22. and 23 full time students? (if yes, please list schools and location)

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.

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.)	Yes	No
1.Digestive system diseases or disorders (including, but not limited to: gastritis, ulcers, esophageal regurgitation, hemorrhoids, colon or rectum disorders)?
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.
3.Respiratory diseases or disorders (including, but not limited to: chronic cough, bronchial asthma, bronchitis, tuberculosis, lung disorders, emphysema, respiratory insufficiency, pleurisy pneumonia)?
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)?
5.Sexually transmitted diseases or immune deficiency disorder (AIDS / ARC), tested positive for HIV or any related illness?
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)?
7.Diabetes? (If "Yes", complete the following) 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): ____________
8.Diseases or disorders of the mental and nervous system (including, but not limited to: epilepsy, convulsions, paralysis, stroke, seizures, chronic headaches, mental retardation, psychosis, mental or behavioral disorders, Down Syndrome or other chromosome disorders, dizziness, fainting spells, vertigo, depression, anxiety, chronic fatigue, eating disorders)?
9.Addictive diseases or disorders (including, but not limited to: alcoholism, chemical or drug abuse or addiction, or has any applicant used illegal drugs or used prescription medication, other than as prescribed)?
10.Kidney or urinary tract system diseases or disorders (including, but not limited to:kidney or bladder stones and infections)?
11.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)?
12.Muscular or skeletal diseases or disorders and inflammation (including, but not limited to: scoliosis, arthritis, rheumatism, gout, tendonitis, joint or vertebrae disorders, osteoporosis)?
13.Any congenital defect, physical disorder or deformity, or developmental problems, not listed above? Or have you or any applicant been advised to have any diagnostic tests, x-rays, electrocardiograms, radiology or blood work, consulted a therapist, physician, chiropractor, psychologist, or other health care practitioner for medical advise regarding the need for hospitalization, surgery, or treatment?
14.For male applicants, diseases or disorders of the reproductive system or prostate?
15.For female applicants, diseases or disorders of the reproductive system or vaginal bleeding, fibroids, nodules or breast cysts, fallopian tubes, ovaries or uterus?
16.For female applicants, are you currently pregnant or had a complicated pregnancy or delivery? If currently pregnant, when is the expected due date? ___________________
17.Have you or any applicant ever been rejected, ridered, cancelled, or had premium increased for any Health, Life or Disability Policy?
18.Are you or any applicant currently hospitalized, disabled or unable to perform normal activities?
19.In the last 12 months, have you or any applicant used any form of tobacco? If "Yes" what form of tobacco? _________ Quantity: _________ How often: _________
20.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?

SECTION 3. HEALTH HISTORY DETAILS 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.

Name of Person and Question #	Condition / Diagnosis, Treatment Medication Prescribed and Results of Treatment	Dates Seen & Duration	Physician / Clinic Address and Telephone #

Information about prior / other coverage	Yes	No
1. Have you been covered by another medical plan at any time during the past year?
2. Will you be covered under any other medical plan (individual or group) while you are covered under this plan?
3. 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.

Name of Insured(s):		Policy / certificate number:
Type of plan (please circle):	Spouse's employer group plan	Other group plan	Individual Plan
Insurance Company Name:		Phone:
Coverage effective date:		If applicable, termination date:
Reason for termination:	Left employment	Employer canceled plan	Non-Renewal

SECTION 4. DECLARATION AND ENROLLMENT REQUEST / AUTHORIZATION TO RELEASE MEDICAL INFORMATION:

I hereby apply for the Reside Prime program and for the insurance provided by Certain Underwriters at Lloyds, 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: (1) physical condition(s), (2) health history(ies), (3) avocation(s), (4) age(s), (5) occupation(s), and (6) personal characteristics. This authorization includes information about (1) drugs, (2) alcoholism, (3) mental illness, or (4) 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.

SECTION 5. PROGRAM SPECIFICS

Please Circle Your Chosen Deductible: $500 $1000 $2500 $5000

Requested Effective Date: _____ / _____ / _____ (month/day/year) (Effective date must be within 60 days of application date)

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:

PREMIUM CALCULATION AND PAYMENT

Annual Premium for all applicants: ___________

Installment Factor (from right): X ____________
(Checks are only acceptable for annual payments)

Total Premium Submitted: = ____________

Premium Installment              Factors
Annual                                    1.00
Semi-Annual                           .55
Quarterly                                .28
Monthly                                  .10
Important: Checks accepted for Annual Premium Only from U.S. banks

METHOD OF PAYMENT

Method of Payment

Check Money Order MasterCard Visa Discover / Novus Diners Club

Card Number:_________________________________________________________________________________

Expiration Date: ___________________

Name as it appears on credit card: Daytime phone: ___________________

Signature: _________________________________________________________________________________

Billing Address: _____________________________________________________________________________

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 by Visa/MasterCard 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)

AGENT INFORMATION

SRI Agent# 1659     Agent Name: Kim Michaels
Company Name: The Insurance Exchange
Address: 115 Hulls Hwy
City: Southport        State: CT        Zip: 06890-1135
Phone: 203-254-4490      Fax:   661-752-7420

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.

Agent's Signature: _______________________________________________________

Please mail or fax to:
The Insurance Exchange
115 Hulls Hwy
Southport, CT 06890
Fax: 661-752-7420

Certain Underwriters at Lloyd’s, London; Rated A- “Excellent” by A.M. Best

It is important to note that Reside Prime 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 Prime are not regulated by any U.S. state insurance department. The information concerning Reside Prime is not intended to be an offer to sell Reside Prime 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 Prime may not be available in all situations or jurisdictions. For U.S. citizens, Reside Prime is intended for persons living or traveling outside the United States.