Enrollment 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

PROVIDERS

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THE CONTOUR GROUP MEDICAL PLAN
ENROLLMENT/CHANGE FORM

You can not Save/Submit the enrollment form until you have valid employee Id or Contact Us.

Participating Organization:*

Organization Contact Email:*

Agent Of Record Name:

Agent Of Record Email:

Employee Name: (Last)*

(First)*

(Middle)*

Occupation:		Sex:*		Height:*	Ft.
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

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: