SUBSCRIPTION I (we) hereby apply and subscribe on the date of receipt hereof to the Global Medical Services Group Insurance Trust, c/o MutualWealth Management Group, Carmel, IN, or its successor, for the Taian Patriot Exchange Program or the Taian Exchange Select as underwritten and offered by Sirius International Insurance Corporation (publ) (the “Company”), with International Medical Group, Inc. (“IMG”) acting as the Company’s managing general underwriter and plan administrator. I (we) understand and agree: (i) the insurance applied for is not general health insurance, but is intended for my (our) use in the event of a sudden and unexpected illness or injury for which eligible coverage may be available, (ii) I (we) must pay premiums for the entire period of coverage in advance, and no coverage will be effective until this Application has been accepted in writing by the Company or by IMG, (iii) no modification or waiver relating to this Subscription or the coverage applied for will be binding upon the Company or IMG unless approved in writing by an officer of the Company or IMG, and (iv) by submission of this application and/or any future claim for benefits I (we) purposefully initiate and take advantage of the privilege of conducting business with the Company in Indiana, through IMG, and invoke the benefits and protections of its laws. The contract of insurance represented by the Master Policy and evidenced by the Certificate of insurance will be deemed issued and made in Indianapolis, IN, and sole and exclusive jurisdiction and venue for any court action or administrative proceeding relating to this insurance will be in Marion County, Indiana, to which applicant(s) hereby consent(s). I (we) consent and agree that Indiana surplus lines law shall govern all rights and claims raised under this Certificate of Insurance.

MERCHANT LOCATION: IMG’s corporate headquarters is located at 2960 North Meridian Street Indianapolis, IN USA.

ACKNOWLEDGEMENT I (we) understand and agree that: (i) marketing brochures and certificate wordings are available upon request prior to application, (ii) the insurance agent/broker assigned to or assisting with this Application is the agent and representative of applicant(s) and in no way acts as agent for the Company or IMG, (iii) any injury, illness, sickness, disease, or other physical, medical, mental or nervous disorder, condition or ailment that, with reasonable medical certainty, existed at the time of application or at any time during the three years prior to the effective date of the insurance, whether or not previously manifested, symptomatic or known, diagnosed, treated, or disclosed to the Company prior to the effective date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom (a "pre-existing condition"), will be excluded from coverage under this insurance, (iv) the subjects of insurance applied for are not intended or considered by the applicant(s), the Company or IMG to be resident, located, or to be performed in any particular state of the United States, and (v) the Company, as carrier and underwriter of the plan, is solely liable for the coverages and benefits to be provided thereunder, and IMG acts solely as disclosed agent for the Company and has no direct or independent liability under the Master Policy or any Certificate of Insurance.

MEDICAL RELEASE I (we) authorize any doctor, practitioner of the healing arts, hospital, clinic, health care related facility, pharmacy, government agency, insurance agency, insurance company, group policyholder, employee or benefit plan administrator having information as to my (our) care, advice, treatment, diagnosis or prognosis of any physical or mental condition, and/or employment status, to provide such information to IMG and/or the Company and my producer/broker involved in procurement of this application and/or insurance coverage. CERTIFICATION I (we) hereby certify, represent and warrant to IMG and the Company that: (i) I (we) have read the questions contained in this Application or they have been read to me (us), and I (we) understand them, (ii) my (our) responses to the questions are true, accurate and complete in all respects as of the date hereof, and that I (we) will supplement such responses prior to the requested effective date in the event of any change or addition thereto, (iii) I am (we are) currently in good health and, except for the conditions and other information disclosed herein, I (we) have not been diagnosed with, sought consultation or been treated for, and have not experienced manifestation or symptoms of and do not suffer from any pre-existing condition which I (we) foresee may require treatment in the future or for which I (we) intend to claim under this insurance, and (iv) if this Application is signed as guardian or proxy of the applicant, the signer warrants their authority and capacity to so act and bind the applicant. By acceptance of coverage and/or submission of any claim for benefits, the applicant ratifies the authority of the signer to so act and bind the applicant.

TAIAN FINANCIAL, LLC. I (we) acknowledge and agree that this Subscription is between the Company and me (us) and no one else. TaiAn Financial, LLC (“Taian”) is my insurance agent and I authorize Taian to represent me regarding my relationship with the Company. Further, although Taian is not a party to this Subscription, I acknowledge that Taian may rely on the statements I (we) have made in this agreement and I (we) authorize Taian to debit my credit card or applicable account for the total amount due to the Company. This authorization will remain in effect for 12 months, unless earlier revoked by me (us) in writing and Taian actually receives notice of revocation. I (we) further acknowledge that if I (we) revoke Taian’s authority to debit the credit card or applicable account, I (we) may lose insurance coverage. Coverage purchased by credit card is subject to validation and acceptance by credit card company. Coverage purchased by eCheck is subject to confirmation of available funds. I (we) agree to comply with the cardholder agreement and the financial institution’s regulations, rules and/or requirements.


SIGNATURES. I(we) acknowledge that: (i) all applications must be fully completed, signed and dated to be considered; (ii) the application must be signed by the applicant, a guardian, or proxy; and (iii) a guardian must be legally authorized to sign on behalf of a minor applicant (under the age of sixteen (16)). A guardian includes a parent. A Proxy is a person authorized by the applicant to act on their behalf. Acceptance by the Company or IMG online shall be valid acceptance of this Application and Subscription. I (we) also acknowledge and agree that a guardian or proxy that signs the Subscription, electronically or through any other means, warrants their authority and capacity to sign for and bind the applicant and that by accepting coverage and/or submitting a claim for benefits, the applicant ratifies the authority of the guardian or proxy to sign for and bind the applicant.

泰安特设团体协议

承认书 我理解并同意：(i) 泰安是我请求加入的团体的组织者；(ii) 泰安将信赖我注册时提供的信 息；(iii) 最早的保险生效日期为付款成功后的第二天(以美国东部时间为准)。如果在要求的保险生 效日期前我没有付款成功，泰安可以更改我要求的保险生效日期；(iv) 以email形式接收电子保单，不邮寄保单；(v) 团体保险包含管理费，下面是详细规定；(vi) 每一次购买和续保团体收取$5不退还的管理费； (vii) 保险生效前我可以申请取消保险退还保费，但$5管理费是不退还的；(viii) 已经生效的保险没有提交过理赔的话，按没有用过的整月退保并扣除$50手续费；提交过理赔的不能退保。(ix) 退保前向泰安公司说明退保原因并提供相应的证据；(x) 所有的保险服务申请包括对我保单的任何更改申请， 我都将发送电子邮件到泰安邮箱 [email protected]。只有泰安收到我发送到此邮箱的电子邮件以后服务申请才是有效的。

我向泰安证明和保证: (i) 我理解并且同意泰安特设团体协议；(ii) 我已经阅读保险样板合同(Sample Contract) 并同意其所有条款；(iii) 如果我为其他人签名，我保证我有权合法地代表申请人。