Contour Application Form

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CONTACT US:

Azimuth Risk Solutions ^sm , LLC
8520 Allison Pointe Blvd, Suite 220, Indianapolis, IN 46250 USA

service@azimuthrisk.com

P: 888-201-8850 or 317-644-6291
F: 888-201-8851 or 317-423-9620

US Short Term Medical

Trip Protection Plan

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THE CONTOUR GROUP MEDICAL PLAN
EMPLOYER APPLICATION FOR GROUP INSURANCE

EMPLOYER INFORMATION

Company Name:

Employer Contact:

Email Address:

Address:

City:

State:

Zip Code/ Postal Code:

Country:

Telephone Number:

Fax Number:

REQUESTED EFFECTIVE DATE (DD/MM/YY):

INITIAL PAYMENT AMOUNT (ATTACHED HERETO):$

The Contour Group Medical Plan is a surplus lines product underwritten by Certain underwriters at Lloyd’s, London. It is distributed, managed and administered, as agent for and on behalf of certain underwriters at Lloyd’s, London, by Azimuth Risk Solutions, LLC SM .

EMPLOYEE WAITING PERIOD

Please indicate the number of days ALL FUTURE EMPLOYEES have as a Waiting Period following the initial employment start date.

No. of Days:

0 30 60 90

EMPLOYEE ELIGIBILITY

Total Number of Employees:

Total Number of Eligible Employees:

Employees Applying for Coverage:

Employer Contribution

Employer will contribute the following % to Eligible Employee Premium.		Enter % here:
Employer will contribute the following % to Eligible Dependent Premium.		Enter % here:

BENEFIT OPTION

Choose Option	Maximum Limit	Deductible
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Optional Dental:

YES NO

Optional Life:

YES NO

Family Limit(2x or 3x) :

Please make the initial payment check payable to: Azimuth Risk Solutions, LLC. Azimuth Risk Solutions, LLC is recognized as a managing underwriter/ authorized agent and representative on behalf of certain underwriters at Lloyd’s of London.

Enclosed is payment of 1/12th of the estimated annual premium as initial payment and deposit. Employer understands that no coverage shall be effective unless and until notified in writing by Azimuth that Employer’s application has been accepted by Azimuth for and on behalf of the Underwriters. Employer understands that any such acceptance is at the sole discretion of Azimuth. If Employer’s application is accepted, the enclosed deposit will be applied toward payment of the first monthly premium. If Employer’s application is not accepted, Azimuth’s and the Underwriter’s sole obligation will be to return the deposit to Employer. Employer understands that, as an employer employing persons in foreign jurisdictions, Employer may be subject to foreign laws with respect to the provision of medical benefits and/or the insurance of those benefits. Employer understands and agrees that neither Azimuth nor Underwriters have investigated whether or how the purchase of this insurance complies with the laws of any foreign jurisdiction. Employer further understands and agrees that Employer is solely responsible for compliance with all applicable foreign laws.

Applicant Signature

Date

Printed Name

Title

Agent Signature

Date

Agent Name

Agent Number