I CERTIFY that I have read and reviewed the completed application and all the answers and statements I provided on this Application and any attachment which I checked and itemized in section 7 question 25 page 3 hereto is complete truthful to the best of my knowledge and belief. If I did not mark with a “yes” section 7 question 25 on page 3, I understand that no additional information was submitted with this application. All information and answers about all applicants including my eligible dependents listed in this application are true and complete. I understand that the Administrator, Global Assurance Group and Claria Life and Health Insurance Company will rely on all information in this Application in determining whether or not to issue coverage and that any omissions, incorrect or incomplete information will cause claims to be denied and the policy to be modied, cancelled or rescinded at any time upon discovery regardless if the omission, incorrect or incomplete information is related to a claim at hand or not.

I UNDERSTAND that the insurance agent, broker or producer, if any, involved with the respect to the solicitation of the application is located and is transacting his services outside the United Sates and is solely acting as my legal agent and representing my personal interests and as such has no authority to bind, receive payment to his name or his company name and is not acting as the legal agent or representative of the Company.

I UNDERSTAND that this application seeks full disclosure of the information sought and no one has the authorization to alter or exclude any information sought in this application.

I UNDERSTAND that health benets may be limited or excluded for conditions which any insured person has received any medical diagnosis or treatment, or taken any medication, before his or her eective date, according to pre-existing conditions limitations provisions of the plan. If any person requires medical care or treatment after the application for insurance is signed, and before the eective date of this policy, full details must be provided to the insurer for nal approval before coverage is eective. I agree to accept the policy with the terms and conditions as issued, otherwise I will notify my disagreement in writing to the company within the rst ten (10) days of receipt of the insurance policy.

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, employer or any individual having any information about me or my dependents listed on this application to disclose to Global Assurance Group and Claria Life and Health Insurance Company, or its legal representative, any and all such information. The nature of the information authorized to be disclosed includes, but is not limited to any information about: 1.) physical condition(s), 2.) health history(ies), 3.) advocations, 4.) age(s), 5.) occupation(s), and 6.) personal characteristics. This authorization includes information about: 1.)drugs, 2.) alcoholism, 3.)mental illness, or communicable diseases. A photocopy of this application shall be valid as the original. This authorization shall remain valid as long as any insurance is in force.

I UNDERSTAND that the information obtained by use of this Authorization will be used by Global Assurance Group and Claria Life and Health Insurance Company to determine eligibility for benets.

I AUTHORIZE, Global Assurance Group and Claria 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 a may be otherwise lawfully required, or as I may further authorize.

I AGREE that the rules of Claria International Health Plans will be binding on me and all eligible dependents included in my policy. You are advised to keep record of all information you supply to us in connection with this application, including letters. If you would like a copy of this form please inform us.

I UNDERSTAND that I am purchasing this policy as resident of a foreign jurisdiction outside the United States I may be subject to foreign laws with the respect to the type and form of the coverage in which I am enrolling.

I UNDERSTAND that the Application is valid for underwriting for a maximum of 90 days. If the Administrator does not 1. approve policy and 2. receive any pending rider signed and 3. receive premium payment at the Administrator’s oce within the 90 days, application will be void and a new application must be submitted for new underwriting.

I UNDERSTAND that the policy will become eective in accordance with the terms of the eective date and the acceptance of, Global Assurance Group, and Claria Life and Health Insurance Company. I understand that no coverage is in eect until I am notied in writing by Global Assurance Group and Claria Life and Health Insurance Company and advised of the ocial Eective Date. I also understand that if I am not accepted for coverage by Global Assurance Group and Claria Life and Health Insurance Company, it is the sole obligation of Global Assurance Group, and Claria Life and Health Insurance Company to return the premium paid.

I UNDERSTAND that this coverage is not, nor does it intend to be a United States health insurance policy. I understand that it can not be solicited, applied for or purchased in the United Sates. I understand that if this application and policy is solicited and/or, applied for and/or purchased and/or renewed while in the United Sates that this policy will be automatically canceled and voided from inception and premiums retuned. I understand that the coverage in the United States is limited to six (6) months out of the twelve (12) months policy period. If I or any applicant spends more than the allotted six (6) months out of the twelve (12) months policy period in the United States this coverage will be voided and all claims from the void date will not be paid.

I UNDERSTAND that all information I know that is responsive to all questions in this application must be provided in my answers. I understand and agree that any omissions, incorrect or incomplete information may constitute an act of fraud against the insurance company.

This Insurance is not subject to, and does not provide certain of the insurance benets required by, the United States’ Patient Protection and Aordable Care Act (“ACA”). This insurance does not provide, and insurers do not intend to provide, minimum essential coverage under ACA. In no event will benets be provided in excess of those specied in the contract documents. This insurance is not subject to guaranteed issuance or renewability other than as specied in the policy. ACA requires certain US citizens and US residents to obtain ACA compliant health insurance coverage. In some circumstances penalties maybe imposed on persons or persons who do not maintain ACA compliant coverage. Each Insured Person should consult their attorney or tax professional to determine if ACA’s requirements are applicable to him/her.

SIGNATURE OF THE PROPOSED INSURED OR GUARDIAN

SIGNATURE OF PROPOSED INSURED’S SPOUSE

I UNDERSTAND that the Administrator, Global Assurance Group, and Claria Life and Health Insurance Company, will rely on all information on Application submitted in determining whether or not to issue coverage and that any omissions, incorrect or incomplete information will cause claim/s to be denied and the policy to be modied, or rescinded retroactively from issue date at any time upon discovery.

I UNDERSTAND that Administrator, Global Assurance Group, and Claria Life and Health Insurance Company seek full disclosure of the information sought in this application and no one has the authorization to alter or exclude any qualication information sought in this application.

I UNDERSTAND that the approval for cover with CLARIA is based on the questionnaire completed on the application and will be subject to medical records received.

I UNDERSTAND that if any medical conditions are detected before or after approval and before policy is paid and any rider signed will result in modications or cancellation of coverage terms at the administrator discretion.

“Pre-Existing Condition” shall mean any one or more or of the following 1) A condition or symptom that would have caused a person to seek medical advice, diagnosis, care or Treatment prior to the Individual Eective Date of Coverage under this Certicate; 2) A condition for which medical advice, diagnosis, care or Treatment, including Medication, was sought, recommended or received prior to the Individual Eective Date of Coverage under this Certicate; 3) the symptoms which occurred prior to the Individual Eective Date of the Coverage under this Certicate would have allowed a person trained in medicine to make a diagnosis of the condition producing the symptoms: 4) a condition which manifested prior to the Individual Eective Date of Coverage under this Certicate; 5) Expenses for Pregnancy including pre, post, birth, birth complications to the mother or the new born within twelve (12) months after the Individual Eective Date of Coverage under this Certicate.

Representations in Application: Any statement or description made by or on behalf of the Insured Person on the Application for Insurance Coverage is a representation and is not a warranty. A misrepresentation, omission, concealment of fact, or incorrect statement may prevent recovery under the Certicate if either of the following apply; a.) the misrepresentation, omission, concealment of fact, or statement is false and/or fraudulent, whether material or not to the approval of the Coverage for the Insured Person, or b.) if the facts had been known to the Administrator or Company prior to issuance of Coverage, the Administrator or Company would not have issued Coverage, would not have issued Coverage at the same Premium or would have issued an Exclusionary Rider to the Coverage under this Certicate.

When a misrepresentation, omission, concealment of fact, or incorrect statement occurs on the application or accompanying health statements, regardless whether the misrepresentation, omission, concealment of fact, or incorrect statement is related to a possible claim at hand or not, the company at their discretion may choose to either rescind and void the certicate and return all the premium to the payer retroactive to the original Individual Eective Date of Coverage or issue a permanent exclusion for a particular pre-existing condition and deny the claim. In the case that a policy is rescinded any claim payments made on the policy from the eective date until the date the policy is rescinded will be applied towards the return of premium which is retroactive to the Eective Date.

In the case that the administrator decides to apply a pre existing condition exclusion to the policy any past payment amount made towards a claim that was found to be due to a Pre Existing Condition will be added to the Insured’s future renewal premium. Insured will need to pay his renewal premium plus any past payment made by the insurance company for a pre existing condition in order to renew his policy.

SIGNATURE OF THE PROPOSED INSURED OR GUARDIAN

SIGNATURE OF PROPOSED INSURED’S SPOUSE