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.

Taian Group Agreement

I acknowledge and agree that: (i) Taian is the organizer of the group I requested to join; (ii) Taian will rely on the information provided when I registered; (iii) the earliest effective date of the insurance is the day after the payment is successful (Based on Eastern Time). If I fail to make payment before the requested insurance effective date, Taian can change the effective date of my insurance to the day after my payment is successful; (iv) Taian will deliver the electronic insurance policy by email without physically mailing the insurance policy; (v) Taian group insurance includes a management fee, the details are as follows (vi) The member can apply to cancel the insurance for a refund of the premium before the insurance takes effect, but the $ 5 management fee is non-refundable; If you have not submitted a claim, your insurance will be surrendered. (viii) The refund will be for whole months of unused coverage and a $50 cancel fee will be deducted; If you have submitted a claim your coverage can not be cancelled for a refund. (iix) All insurance service requests, including any changes to my policy, will be emailed to [email protected]. The service request will only be valid after Taian receives the email I sent to this email address.

I certify and warrant to Taian: I understand and agree with the Taian Group Agreement; (ii) I have read the Sample Contract and agree to all its terms; (iii) if I sign for someone else, I Guarantee that I have the right to represent the applicant legally.