When do you plan to depart the United States: ______ / ______ / ______ (month/day/year)

	Name of Insureds:	
	Policy Number:
	Type of Plan: 
		&127; Spouse's employer group plan   
		&127; Other group plan    
		&127; Individual plan
	Insurance Company:	
	Phone:
	Effective Date:	
	Termination Date:
	Reason for termination: 
		&127; Left employment   
		&127; Employer Canceled plan   
		&127; Non-Renewal

I hereby apply for the Reside Prime program and for the insurance provided by Certain Underwriters at Lloyds, London (the "Underwriter"). I hereby subscribe to the Global International Trust and enroll in the group coverage for which I am eligible under the group contract issued by Certain Underwriters and Lloyd's, London.

I represent that I have read the completed application and that all my answers and statements on this Application and any attachments hereto is complete and true to the best of my knowledge and belief. I understand that my qualification for insurance is based upon my answers and statements herein and that this information may be verified by Specialty Risk International, Inc. (the "Administrator"). I understand that no one has the authority to exclude or direct me to exclude any information sought by this form. I understand that the Administrator will rely on all information on this Application in determining whether or not to issue coverage and that any incorrect or incomplete information may result in a claim denial or loss of coverage.

I understand that benefits may be limited or excluded for conditions for which any insured person has received any medical diagnosis or treatment, or taken any medication, or realized the manifestation of a condition before his or her effective date, according to the pre-existing conditions limitations provisions of the plan.

I AUTHORIZE any physician, medical practitioner, hospital, clinic, other medical or medically-related facility, the Medical Information Bureau, Inc. (MIB, Inc.), consumer reporting agency, insurance or reinsuring company, or employer having certain information about me or my dependents to give Specialty Risk International, Inc. or its legal representative, any and all such information. The nature of the information authorized to be disclosed includes, but is not limited to, information about: physical
condition(s), health history(ies), avocation(s), age(s), occupation(s), and personal characteristics. This authorization includes information about drugs, alcoholism, mental illness, or communicable diseases.

I UNDERSTAND the information obtained by use of this Authorization will be used by the Administrator to determine eligibility for benefits. I ALSO AUTHORIZE the Administrator to release any information obtained to reinsuring companies, Medical Information Bureau, Inc., or other persons or organizations performing business or legal services in connection with my application, claim, or
as may be otherwise lawfully required, or as I may further authorize.

I UNDERSTAND that as a resident of a foreign jurisdiction, I may be subject to foreign laws with respect to the type and form of coverage in which I am enrolling. I also understand and agree that responsibility for complying with those foreign laws rests solely on me.

I UNDERSTAND that no coverage is effective until I am notified in writing by the Administrator and advised of the official Effective Date. I also UNDERSTAND that if I am not accepted for coverage by the Administrator, the sole obligation of the Administrator and the Underwriter is to return the premium. I also UNDERSTAND that coverage in the United States is limited to 6 months during any one 12 month policy period. I also UNDERSTAND that Lloyds operates as an unauthorized insurer in most US states and that claims may not be made against any state guarantee fund. I UNDERSTAND and AGREE that this program is issued outside the United States and that the program does not comply with any US state insurance law.

I UNDERSTAND that this program is not, nor does it intend to be, a general United States health insurance policy.

I ALSO UNDERSTAND any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an enrollment form, or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

_____________________________________________
(Sign here for Pre-Authorization of Installment Premiums)

Check or money order should be made payable to SRI. All payments must be made in U.S. dollars, from a U.S. Bank, and submitted at the time application for coverage is made.

Agent Information

Security Certain Underwriters at Lloyd's, London; Rated A- "Excellent" by A.M. Best and A+ "Strong" by Standard and Poors.

Please mail or fax to
Sunburst Worldwide Insurance Services
P.O. BOX 1016, Clovis, CA, 93613 USA
Fax: 317-575-2659
If you pay premium with credit card, you may fax your application.