Customer Add/Change Form for Term Life

Transcription

1 Instructions 1. Print clearly and complete this form in ink. 2. For each person to be covered, provide all requested information. 3. Complete Sections 1, 2 and 4; other items as directed. 4. Primary policyholder listed in Section 1 must initial and date any corrections. Do not use correction fluid. 5. Important: Failure to follow these instructions will cause a delay in processing your form. Anthem Life Insurance Company P. O. Box Roanoke, VA Customer Service Phone Number: Customer Service Fax Number: Customer Add/Change Form for Term Life This form can be used to add or change term life coverage for currently existing policies. KeyCare Flexible Choice KeyCare HealthSmart KeyCare HealthSmart with Enhanced Drug Benefit Lumenos Health Incentive Account (HIA) Lumenos Health Incentive Account Plus (HIA Plus) Lumenos Health Savings Account (HSA) 1. Primary Policyholder Information Primary Policyholder Last Name First M.I. Social Security Number 2. Indicate Policy Add or Change Please choose one of the following: INCREASE the amount of your Optional Term Life Insurance Complete and sign the attached Anthem Life application on the back page if you have had Anthem Life coverage for more than a year. Covered domestic partners wanting an increase must also sign. $50,000 coverage for you and $50,000 coverage for your spouse; and $15,000 coverage per dependent child For those with Lumenos health plans only: $75,000 coverage for you and $75,000 coverage for your spouse; and $15,000 coverage per dependent child Your start date will be the first of the month following approval of this form. ADD Optional Term Life Insurance Complete and sign the attached Anthem Life application on the back page. The $75,000 option is available only with Lumenos health plans. Any spouse or domestic partner wanting coverage must also sign the application. You may ignore the application s 8 health questions only for family members who have had Anthem Blue Cross and Blue Shield medical coverage for less than a year. Your start date will be the first of the month following approval of this form. The coverage is issued as a separate policy from your health insurance policy, and will be insured by Anthem Life Insurance Company. Any approved domestic partner will receive his/her own separate life policy. DECREASE the amount of your Optional Term Life Insurance $25,000 coverage for you and $25,000 coverage for your spouse; and $15,000 coverage per dependent child $50,000 coverage for you and $50,000 coverage for your spouse; and $15,000 coverage per dependent child DELETE your Optional Term Life Insurance Your Optional Term Life coverage will cancel at the end of the month following receipt of this form. DESIGNATE or CHANGE beneficiaries for a current policyholder s Optional Term Life coverage, or for a newly added dependent to this policy Complete Section 3. Anthem Life Insurance Company is an affiliate of Anthem Blue Cross and Blue Shield. Agent AVA1579 An independent licensee of the Blue Cross and Blue Shield Association. Page 1 of 3

2 3. Beneficiary Designation Please complete the information below for each person to be added on this form. Each applicant can have multiple beneficiaries. Use an additional sheet of paper if necessary. All additional pages must be signed and dated by the primary applicant. DEFINITIONS 1. Primary Beneficiary The Primary Beneficiary is the person designated to receive the proceeds of a life insurance policy following the death of the insured. 2. Contingent Beneficiary The Contingent Beneficiary is the person who will receive the death benefit if the primary beneficiary should die before the person whose life is insured. 3. Percentage of Allocation The Percentage of Allocation is the percentage amount of the term life insurance death benefit that an applicant designates to his/her beneficiary(ies). For example, a 60% allocation to a beneficiary would leave that percentage of the death benefit proceeds to that individual. (See example below.) First Name of Member Beneficiary Full Name (and Jr./Sr. if applicable) Beneficiary Social Security Number Relationship to Member Allocation Percentage of Allocation (must add up to 100% for each applicant) EXAMPLE Jane Doe % John John Doe, Jr % Lynne Smith % Please check box if an additional sheet(s) of paper has been completed for this section. Primary Policyholder Please check box if an additional sheet(s) of paper has been completed for this section. Agent AVA1579 Page 2 of 3

3 3. Beneficiary Designation (continued) First Name of Member Beneficiary Full Name (and Jr./Sr. if applicable) Beneficiary Social Security Number Relationship to Member Allocation Percentage of Allocation (must add up to 100% for each applicant) Spouse or Domestic Partner Please check box if an additional sheet(s) of paper has been completed for this section. Child Please check box if an additional sheet(s) of paper has been completed for this section. 4. Certification This section must be signed and dated to avoid delays in processing. I/We, the undersigned, request that Anthem Life fulfill my selected request(s) in this application. If indicated in Section 2, I will complete the attached application. Signature of Applicant or print and sign name of Legal Representative Signature of Spouse/Domestic Partner or print and sign name of Legal Representative Signature of Other Adult Person to be covered or print and sign name of Legal Representative Signature of Agent Agency Number Agent Number Agent AVA1579 Page 3 of 3

4 Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols Agent LIF G 1105 INA VA are registered marks of the Blue Cross and Blue Shield Association. Page 1 of 1

5 Important Notice: Replacement of Life Insurance or Annuities You are contemplating the purchase of our life insurance policy. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy to pay all or part of any premium or payment due on the new policy. A finance purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacement before you make your purchase decision and ask that you answer the following questions and consider the questions on the following page. YES NO Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to insurer, or otherwise terminating your existing policy or contract? Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? If you answered YES to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing: Insurer Name Contract or Policy Number Insured or Annuitant Replaced or Financing REPLACED FINANCING REPLACED FINANCING Please check box if an additional sheet(s) of paper has been completed for this chart. Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision. The existing policy or contract is being replaced because: Signature and Printed Name of Primary Applicant Signature and Printed Name of Agent I do not want this notice read aloud to me (Primary applicant must initial if not wanting this notice read aloud.) AVA1689 Page 1 of 2

6 Important Notice: Replacement of Life Insurance or Annuities (continued) Questions to Consider A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether the replacement or financing of your purchase makes sense: Premiums: Are they affordable? Could they change? You re older are premiums higher for the proposed new policy? How long will you have to pay premiums on the new policy? How long will you have to pay premiums on the old policy? Policy Values: The proposed new policy has no cash values and pays no dividends does your existing policy or contract? Acquisition costs for the old policy may have been paid, and you will incur costs for the new one. What surrender charges do the policies have? What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? Insurability: If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. You may need a medical exam for a new policy. Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage. If you are keeping the old policy as well as the new policy: How are premiums for both policies being paid? How will the premium on your existing policy be affected? Will a loan be deducted from death benefits? What values from the old policy are being used to pay premiums? If you are surrendering an annuity or interest sensitive life product: Will you pay surrender charges on your old contract? What are the interest rate guarantees for the new contract? Have you compared contract charges or other policy expenses? Other issues to consider for all transactions: What are the tax consequences of buying the new policy? Is this a tax-free exchange? (See your tax advisor.) Is there a benefit from favorable grandfathered treatment of the old policy under the federal tax code? Will the existing insurer be willing to modify the old policy? How does the quality and financial stability of the new company compare with your existing company? AVA1689 Page 2 of 2

7 THIS PAGE INTENTIONALLY LEFT BLANK.

8 Anthem Life Insurance Company is an affiliate of Anthem Blue Cross and Blue Shield. An independent licensee of the Blue Cross and Blue Shield Association.