By completion of this enrolment, the I hereby apply to be a Plan Participant of the Global Solutions Insurance Trust (the “Trust”) and to participate in the insurance coverage extended to participants under the Trust by H&W Indemnity (SPC) Ltd. for and on behalf of Global Solutions SP (the “Company”) to Plan Participants under the Trust (the “Coverage”). I understand that the Coverage is not a general health insurance product, but it is intended for use in the event of a sudden and unexpected event while traveling outside of my home country. I understand that I may obtain full details of the coverage by requesting a copy of the master policy from the Administrator. I understand that the liability of the Company is as provided in the Master Policy.
The Plan Participant hereby agrees to and accepts all terms and conditions of the applicable master policy, full details of which can be obtained from the Administrator. By acceptance of the coverage and/or submission of any claim for benefits, the plan participant ratifies the authority of the signer to so act and bind the plan participant. The Plan Participant hereby undertakes to make all premium payments as they fall due in respect of the coverage extended to them and acknowledges that in the event of any failure to do so, then the coverage will lapse (unless otherwise agreed in writing by the Underwriter).
The Plan Participant hereby confirms the accuracy and validity of all information, representations and warranties provided in connection with their enrolment for coverage, howsoever provided, including the terms of this subscription agreement and the information contained in the enrolment form (together “Representations & Warranties”). The Plan Participant acknowledges that certain of such information will be relied upon by the Underwriter as provider of the coverage, and that any inaccuracy therein may result in the invalidity of such coverage as it relates to the Plan Participant, the loss of coverage and all monies paid in relation thereto.
The Plan Participant hereby undertakes to inform the Administrator of any change to any matter that forms the subject of the Representation & Warranties. The Plan Participant hereby undertakes to indemnify and hold harmless the Administrator against any loss or damage (including attorney’s fees) occasioned by any inaccuracy in any representation & warranty or failure to advise the Administrator of any change in any matter that forms the subject of any of the representation & warranties. The Plan Participant agrees that the Administrator shall be entitled to rely on and to act in accordance with any written instruction purported to be provided by, or on behalf of, the Plan Participant and the Plan Participant hereby undertakes to indemnify and hold harmless the Administrator against any loss or damage (including attorney’s fees) occasioned by the Administrator acting in accordance with such instruction. Payments under the terms of coverage shall be paid by the Underwriter, ITA Global Trust Ltd., or any duly appointed administrator either directly to a provider or to the Plan Participant.
I confirm that I have satisfied myself that the insurance is appropriate for me and that I meet the eligibility criteria. The policy provides limited benefit short duration coverage pursuant to all its terms, conditions, and limits, and exclusions. It is not subject to, and does not provide, certain insurance benefits required by the United States’ Patient Protection and Affordable Care Act (“ACA”). ACA requires certain U.S. citizens or U.S. residents to obtain ACA compliant coverage. Since January 1, 2014, ACA requires U.S. citizens, U.S. nationals and resident-aliens to obtain ACA compliant health insurance coverage, or “minimum essential coverage.” ACA also requires certain employers to offer PPACA compliant coverage to their employees. Tax penalties may be imposed on persons who are required to maintain ACA compliant coverage but do not do so. In certain cases, individuals may be deemed to have minimum essential coverage under ACA even if their insurance coverage does not provide all the benefits required by ACA. Eligibility to purchase this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including ACA. Insured Persons should consult their attorney or tax professional to determine whether this coverage meets any obligations they may have under ACA. This plan is not designed to cover US citizens or residents. This insurance is not subject to guaranteed issue or renewability.