The MEGA Life and Health Insurance Company 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 KNOW that I may request to receive a copy of this Authorization. I also understand and agree that responsibility for complying with those foreign laws rests solely on me. All premium payments must be made in U.S. dollars. This authorization will remain in effect until revoked by me in writing, and until SRI actually receives notice.
Coverage purchased by credit card is subject to validation and acceptance by credit card company.
For any installment payment other than annual, I pre-authorize SRI to debit my credit card for the proper installment amount on the due date of the installment. To the best of my knowledge, the application is truthful and accurate. Copyright 1998-2001 by Specialty Risk International, Inc., Used by permission. If the Applicant desires to pay premiums on a Semi-Annual, Quarterly or Monthly basis, they must do so by Visa or Master Card payment only. SRI will automatically debit the credit card on the due date of the premium installment.