By signing below, I, the Insured Person, agree and acknowledge that:

(1) Any payments made to an alternate payee for benefits, reimbursements or amounts owed under the Insurance Contract shall discharge IMG’s duties under the Insurance Contract as if those payments had been made directly to me and that any amounts owed under the Insurance Contract shall be paid to the alternate payee

(2) This form shall not be used to assign any benefits owed to me to any medical care provider and that if any of the alternate payees listed above are medical care providers who provided care to me or someone covered under my Insurance Contract, this form is null and void

(3) This form—even if signed and authorized—does not alter, amend, or in any way affect the terms and conditions of the Insurance Contract

(4) If there is any conflict between this form and the Insurance Contract, the Insurance Contract supersedes this form

(5) even if IMG authorizes the transfer of payment to the alternate payee pursuant to this form, such authorization has no effect on the eligibility of any claim or the nature, amount or existence of any benefit

(6) To the extent required by the laws of my state or any applicable jurisdiction, my spouse has authorized me to sign this document and I will not use this document to avoid or violate my spouse’s rights to any community or marital property