We will not accept checks or money orders for quarterly or semi-annual payment modes. Either checks or credit cards may be used for annual payment modes. Please make all checks payable to International Medical Group SM , Inc . All payments must be made in US dollars at the time Application for coverage is made. This authorization will remain in effect until revoked by me in writing, and until IMG SM actually receives notice.
Coverage purchased by credit card is subject to validation and acceptance by credit card company.
For any mode other than Annual, I pre-authorize IMG SM to debit my credit card for the proper installment amount on the due date of the installment. The company reserves the right to request additional medical information. Please list Beneficiaries for additional Dependents. Please provide the full name, address, and percent of death benefit required.