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Azimuth Risk Solutions sm , LLC
5218 S East St, Suite E-1, Indianapolis, IN 46227 USA

service@azimuthrisk.com

P: 888-201-8850 or 317-644-6291
F: 888-201-8851 or 317-423-9620
 
 
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THE CONTOUR GROUP MEDICAL PLAN
ENROLLMENT/CHANGE FORM
 
THIS FORM IS FOR:*
Employee Only Employee + Spouse Employee + Child(ren) Family
Late Enrollment Name Change Addition of Dependent(s) Removal of Dependent(s)
Address Change Beneficiary Change Termination Notice    
Participating Organization:* Organization Contact Email:*
Agent Of Record Name: Agent Of Record Email:
Employee Name: (Last)* (First)* (Middle)*
Occupation: Sex:* Height:*
Citizenship:*  Male
 Female
Weight:*
Resident Street Address:* Resident City / State / Postal or Zip Code:*
Telephone Number:* Email:*
Identification Number / Social Security Number: Date of Birth :*
(MM/DD/YYYY)
Requested effective date (MM/DD/YYYY):* Date Employed Full Time (MM/DD/YYYY):* Hours Worked Per Week:*
Departure Date from U.S. (if applicable):
(MM/DD/YYYY)
Country of Destination:* Length of Stay:*
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.
 
DEPENDENTS  (How many dependent children)
Name (Last, First, Middle) Sex Date of Birth
(MM/DD/YYYY)
Citizenship
Spouse:
Male
Female
Identification Number: Height: Weight:
Name (Last, First, Middle) Sex Date of Birth
(MM/DD/YYYY)
Citizenship
Child #1
Male
Female
Identification Number: Height: Weight:
For dependent children age 19 or older, please indicate name and address of college or university and the number of hours enrolled below:
I refuse coverage for : Myself Spouse Children Reason:
I have been given the opportunity to participate in the group insurance plan offered though my employer and I have refused to participate in the coverage as indicated above. I understand that if coverage is desired at a later date, I may be required to furnish, at my own expense, satisfactory evidence of insurability before coverage becomes effective. (SIGN HERE ONLY IF REFUSING COVERAGE)
Signature: Date
(MM/DD/YYYY):
 
Printed Name:  
 
  

 

 


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