Applicant information: Patriot Travel Medical Insurance^sm
Please print clearly

(Circle one) Mr. Mrs. Ms.

Last Name_______________________________

First Name___________________________Middle________________

Passport Number____________________________________

Issuing Country__________________________________

Send Confirmation of Coverage to:

Name__________________________________________________________________________

Address________________________________________________________________________

City_________________________________State_________Zip Code__________________

Country_____________

Beneficiary_________________________________________

Relationship to Applicant__________________________

Insured will be beneficiary for spouse & children

Calculating Your Premium:

Select the coverage plan and plan option: (Check one plan and one option).

Payment must be for total number of months you want coverage. Refund of premium will be made only if a written request is received by IMG prior to the effective date of coverage. After that, the premium is fully earned and non refundable. All payments must be made in US Dollars.

Payment Method Check (To IMG) / Money Order (To IMG) / Mastercard / Visa / Amex

Card #_____________________________________________

Expiration date___________ Phone________________________________

Name on Card________________________________________________Signature______________________________

SUBSCRIPTION I (we) hereby apply and subscribe to the Global Medical Services Group Insurance Trust, c/o Union FederaI Savings Bank, Indianapolis, IN, for Patriot Travel Medical Insurance^SM underwritten by Sirius International Insurance Corporation (publ) (the Company). I 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 is available, (ii) coverage under the Patriot International^SM and Patriot America^SM plans is not renewable, (iii) 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, (iv) no modification or waiver relating to this Application or the coverage applied for will be binding upon the Company unless approved in writing by an officer of the Company, and (v) the Master Policy is issued in the United States, and is governed by its laws.

ACKNOWLEDGEMENT I understand and agree that this insurance does not provide benefits for any injury, illness, sickness, disease, or other physical, medical, mental or nervous condition, disorder or ailment that existed at the time of application or at any time during the five years prior to the effective date of this insurance, including any subsequent, chronic or recurring complications or consequences relating thereto or arising therefrom (a "pre-existing condition"), whether or not previously manifested or known, diagnosed, treated, or disclosed, and that all charges and/or claims for pre-existing conditions will be excluded from coverage under this insurance. MEDICAL RELEASE I (we) hereby authorize any doctor, practitioner of the healing arts, hospital, clinic, health 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 for any physical or mental condition, or financial and employment status, to provide such information to IMG and/or the Company.

CERTIFICATION I hereby certify, represent and warrant that: (i) I have read the foregoing statements or they have been read to me, and I understand them, (ii) I am (we are) eligible to participate in this insurance program, (iii) I am (we are) currently in good health and have not been diagnosed with, treated for, and do not suffer from any pre-existing or other medical condition which I (we) foresee may require treatment in the future or for which I (we) intend to claim under this insurance. If signed as proxy of the Insured, the undersigned warrants their authority and capacity to so act and to bind the Insured. By acceptance of coverage, the insured ratifies the authority of the signatory to bind Insured.

PATRIOT INTERNATIONAL^sm 
For U.S. Citizens Travel Medical Insurance for U.S. citizens traveling abroad. Patriot International^sm has 3 benefit options.

PATRIOT AMERICA^sm 
For Non-U.S. Citizens U.S style Travel Medical Insurance for non-U.S. citizens traveling outside their country of citizenship. Patriot America has 3 benefit options.

EXPATRIOT PLUS^sm 
For All Long Term Travelers. ExPatriot Plus^sm must be issued for a minimum of 6 months and is renewable for up to 2 years. ExPatriot^sm has a $1,000,000 benefit.

Premiums effective through 12/31/02.

*A dependent child is your child shown on the Enrollment Form under 18 years of age, traveling with you, and for whom premium has been paid.