Group Life Insurance Amounts. Basic $ Voluntary $ Group Life Insurance Amounts. Spouse Effective Date: Child(ren) Effective Date:

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Group Life Insurance Amounts. Basic $ Voluntary $ Group Life Insurance Amounts. Spouse Effective Date: Child(ren) Effective Date:"

Transcription

1 DIRECTIONS: CONVERSION KIT GROUP LIFE INSURANCE (MONTANA) 1. Complete a separate Conversion Kit for each applicant. 2. Complete all sections below and the attached conversion application. 3. Mail the completed form below, the completed application, the signed Important Information About Your Life Insurance Conversion, initial premium and bank draft form to the above address within 31 days of the date your group insurance terminates. Checks or Money Orders should be made payable to Texas Life Insurance Company. In accordance with and subject to all the terms and conditions of the conversion privilege contained therein, I make application to Texas Life Insurance Company to convert my insurance under said Group Policy to an individual plan issued by Texas Life Insurance Company, such policy to be used in accordance with the following requests and statements of fact: Name of Employer: TO BE COMPLETED BY EMPLOYEE Group Policy Number: Name of Employee (Last, First, Middle): Employee s Social Security Number: Present Occupation: Date and Reason for Termination: Employee: Basic $ Voluntary $ Name of Employer: Group Life Insurance Amounts Spouse: Basic $ Voluntary $ TO BE COMPLETED BY EMPLOYER Child(ren): Basic $ Voluntary $ Group Policy Number: Employee Ineligible for Coverage: Date: Employee Effective Date: Group Policy Terminated: Date: Group Life Insurance Amounts Spouse Effective Date: Child(ren) Effective Date: Basic $ Voluntary $ Employee Date: Basic $ Voluntary $ Date Coverage Terminated Spouse Date: Basic $ Voluntary $ Child(ren) Date: Name of Person Authorized to Certify for Group Policyholder (please print) Telephone Number Signature of Person Authorized to Certify for Group Policyholder Date Signed *For rates under age 17 and over age 70, please contact Texas Life Insurance Company at (800) , ext. 6819

2

3 Important Notice Regarding Your Accelerated Death Benefits Important Notice The Insurance proceeds, cash values and loan values will all be reduced to zero and will no longer be payable and Texas Life s obligation under the contract will terminate if Texas Life pays you the Accelerated Death Benefit under this Rider. Important Tax Notice The Accelerated Death Benefit under this rider is intended to qualify for favorable tax income treatment under the Internal Revenue Code of 1986 (as amended by Public Law in Washington state). If the Accelerated Death Benefit qualifies for such favorable tax treatment, the benefit will be excludable from your income and not subject to federal income taxation. Tax laws relating to acceleration of life insurance benefits are complex. You should consult a qualified tax or legal advisor to determine the effect on you. Neither Texas Life nor its agents are authorized to give tax or legal advice. Public Assistance Notice Receipt of the Accelerated Death Benefit may affect your, your spouse s or your family s eligibility for medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance programs. You should consult a qualified tax or legal advisor and social services agencies concerning how receipt of such payment will affect you, your spouse s, and your family s eligibility for public assistance. Rider Mechanics The policy includes an Accelerated Death Benefit Due to Terminal Illness Rider, Form ICC11-ULABR-11 in states which are members of the Interstate Insurance Compact (ICC*) and Form ULABR-11 in non-icc states. If the insured becomes terminally ill you may elect to claim an accelerated death benefit while the insured is still alive in lieu of the insurance proceeds otherwise payable at death. The single sum benefit is 92.6% (92% in AR, AZ, CA, CT, FL, DE, MT, ND, OR, and SD) of the insurance proceeds less an administrative fee of $150 ($100 in Florida and $150 premium in Montana). This is not a long term care benefit. Terminal illness is an injury or sickness diagnosed and certified by a qualifying physician that, despite appropriate medical care, is reasonably expected to result in death within 12 months (See your rider for additional detail regarding the certification of terminal illness). A 90 day exclusion period applies in AZ, AR, CA, DE, DC, FL, MT, ND, and SD (30 days in CT) unless the terminal illness results from accidental bodily injury. Other conditions and limitations apply. The right to accelerate benefits under this rider does not extend to any Family Term Life Insurance Rider. However, if the Accelerated Benefit is paid, The Family Term Life Insurance Rider results in coverage becoming paid-up as if the Insured had died. Payment of the Accelerated Death Benefit terminates the policy and all other optional benefit/riders without further value. In AZ, AR, CA, CT, DE, DC, FL, MT, ND, OR and SD, this rider cannot be reinstated after a policy lapses. So, pay your premiums faithfully.

4 Instructions for Completing Application 1. On the Individual Life Insurance Application, complete all highlighted areas. (complete only the highlighted areas) 2. Print your Last Name, First Name, Middle Initial, Sex (M/F), Social Security Number, Birth Date, and your age as of the 1 st of the month following the completion of this application. If completing this application for a minor child (under the age of 18), please provide their information instead of your own. 3. Answer the tobacco question Yes if you have used any form of tobacco within the last 12 months and No if you have not. 4. Print your mailing address, daytime phone number, evening phone number and address in the boxes provided. This will only be used in the processing of this application and the ongoing administration of this plan. 5. Print the full name and relationship of your beneficiary in the boxes provided. 6. Use the attached rate sheet to select your face amount and the monthly premium. Locate your age as of the 1 st of the month following the completion of this application and follow across to the appropriate face amount and the applicable tobacco usage column. This will be your monthly bank draft premium. If your requested face amount is not listed on the rate sheet, see attached instructions on calculating your premium. 7. Record the face amount (not to exceed the lesser of your Group Life insurance amount or $150,000), premium and total premium in the boxes provided. 8. If you would like to include the Automatic Contract Loan provision, check the appropriate box. You may choose to include an Automatic Contract Loan provision which pays any unpaid premiums for a policy that has sufficient cash value when the premium is overdue 30 days or more. 9. Turn to the back of the application; review the appropriate disclosure notices and then sign the application as the Proposed Insured. For applicants under the age of 18, the application must be signed by the legal guardian, making them the owner of the policy. Date the signature with the current date, and then add the City and State where the application was signed. 10. Attach a check or money order made payable to Texas Life Insurance Company to the application for the 1 st month s premium. Your initial premium will be the bank draft premium amount. See step 9 for all subsequent premiums. Your application is incomplete without the 1 st premium attached. 11. Read and sign the Important Information About Your Life Insurance Conversion form that follows the application. Your application is incomplete without this form being signed. 12. Please complete the attached bank draft form, attach a voided check or deposit slip and mail with your completed application. If you choose not to complete the bank draft form, you will receive a monthly bill which will include a $2.00 monthly billing fee. 13. Use the attached postage paid envelope to mail the completed cover sheet, completed application, signed Important Information About Your Life Insurance Conversion, initial premium and bank draft form to the address below within 31 days of the date your group insurance terminates: Texas Life Insurance Company Conversion Application New Business P. O. Box 830 Waco, TX For assistance with your conversion application, please call , ext and ask for LifeMap Conversion Expert assistance.

5 INDIVIDUAL LIFE INSURANCE APPLICATION FOR HOME OFFICE USE ONLY 1 st Deduction Date: Employer: LifeMap Conversion Policy Number: Proposed Insured Personal Information Last Name First Name SSN Birth Date Age (1) MI Sex Hire Date Tier 1 Within the last 12 months have you used tobacco in any form? Yes Are you at work on a full-time basis, performing your usual duties?... Yes No No Street/PO Box City State Zip Phone: Day Evening Beneficiary Name : Relationship: Will proposed coverage replace or change any existing insurance or annuity policy? Yes No (if Yes identify and complete replacement form.) Company Policy Number Do you have existing insurance or annuities (including coverage with Texas Life)? Yes No If Yes complete the Existing Insurance Form even if replacement is not contemplated. Face Amount (2) Premium Rider Premium Total Premium Coverage Information Plan of Insurance: SOLUTIONS Series 121 Select Riders to be Added: Family Term Rider Accidental Death (3) Waiver Premium (3) Payroll is per: Weekly Bi-Weekly Semi-Monthly Monthly Skip I elect the Automatic Contract Loan provision to pay a premium overdue 30 days or more, if my policy has sufficient cash value. Tier 2 Questions (If answered Yes no coverage is offered, except as available under Tier 1 questions) During the last 24 months have you been treated for, been prescribed medication for, or been diagnosed by a member of the medical profession as having, any of the following: Yes No a. Cancer (excluding non-melanoma skin cancer? b. Heart attack, coronary artery or valve disease, heart failure or cardiomyopathy? c. Alcohol or drug abuse? d. Diabetes for which the recommended treatment is insulin? e. Chronic obstructive pulmonary disease (COPD), emphysema or other chronic lung disease (excluding asthma)? f. Stroke or transient ischemic attack (TIA)? g. Chronic kidney disease or kidney failure (excluding kidney stones)? h. Parkinson s disease or paralysis? i. Cirrhosis of the liver or hepatitis (excluding Hepatitis A)? j. Acquired Immune Deficiency Syndrome or tested positive for the Human Immunodeficiency Virus (HIV) or its antibodies? (1) Age on Issue Date (2) or Face Amount purchased by premium shown, if less (3) Proposed insured (employee) issue ages Form: 11M009 R 12-11

6 Additional Statements For residents of AL, DC, IN, and OR: I received a summary description of the accelerated death benefit and Important Notice regarding Accelerated Death Benefit. For residents of Arkansas: Any person who knowingly and with intent to defraud any insurance company or other person files an application containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. For residents of Washington, DC: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment, and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. REPRESENTATIONS: I believe to the best of my knowledge and belief that all statements and answers in this application are complete, true and correctly recorded, and are made as a consideration for the insurance applied for. I understand that Texas Life Insurance Company will rely on my statements and answers as being true and complete in deciding whether to issue insurance on the proposed insured. Insurance is effective under the policy only when it is delivered to the owner and the full first premium is paid in cash. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Proposed Insured (Owner) Signature X Date City State Agent Only: To the best of my knowledge the insurance applied for is is not to replace existing insurance or annuity. I have delivered to the Proposed Insured the applicable forms and information described in Additional Statements above. Enroller Print Signature X Regence Coordinated Services Inc Enroller Name Agent # _LM18721 Interim Insurance Interim insurance will be in force on the application date if these conditions are met: (1) the insurance is purchased through payroll deduction or through your membership in a union or association; (2) you sign a Salary Deduction Authorization or Bank Draft Authorization Form (union and association members only); and, (3) you are insurable at standard rates under Our rules and usual practice. Interim insurance remains in effect until the earlier of: (a) the Policy Date; (b) the date We decline the application; (c) the date We notify you that you are ineligible for interim insurance; or, (d) the 180 th day after the application date. In Kansas, clauses (3) and (d) do not apply, and clauses (b) and (c) apply only when We refund all premiums. Form: 11M009 R 12-11

7 Important Information About Your Life Insurance Conversion You have decided to convert the life insurance coverage you had under the LifeMap Assurance Company (LifeMap) Group Life Insurance Policy (Group Policy) that you acquired through your former employer, to an individual life insurance policy (individual policy), to be issued by Texas Life Insurance Company (Texas Life), a Texas domestic insurance company which is authorized to do business in all states other than New York. Texas Life has a financial strength rating of A (Excellent) from AM Best Company. A Best s Financial Strength Rating is an independent opinion of an insurer s financial strength and ability to meet its ongoing insurance policy and contract obligations. It is based on a quantitative and qualitative evaluation of a company s balance sheet strength, operating performance and business profile. As part of the conversion process, Texas Life wants to make you aware of the following important items. 1. Coverage under the Group Policy extends for 31 days past the date you ceased to be eligible for such coverage. Should the insured die within that time period, life insurance coverage will still be provided by the Group Policy and not by Texas Life. If the insured dies during the conversion process only one death benefit will be paid; either through the Group Policy or by the Texas Life policy 2. The Interim Insurance provision set out on the back of the Texas Life application form does not apply to your Texas Life policy because its terms do not apply to a conversion. Instead, the following Interim Insurance provision will apply. Interim Insurance Interim Insurance will be in force on this application to convert the applicant s group policy voluntary coverage beginning on the first day after the applicant no longer has coverage under the Group Policy if these conditions are met: (1) the applicant submits an application to Texas Life for such conversion in accordance with the attached instructions; and (2) the first month s premium for the policy as shown on the enclosed monthly premium chart is paid. Interim Insurance will remain in effect until the Policy Date so long as all premiums therefore are paid. 3. Your Group Policy provides that any time period the insured was covered by the Group Policy will apply to any contestability or suicide exclusion provisions contained in the converted policy. Even though the Individual Policy that will be issued to you by Texas Life contains specific contestability period and suicide exclusion provisions, the time period that you were covered under the Group Policy will be considered in determining the incontestability or suicide exclusion time period under the Individual Policy issued to you by Texas Life. 4. The Individual Policy is issued by Texas Life rather than LifeMap. Your rights and remedies will be against Texas Life rather than LifeMap. Texas Life makes no representation or warranties as to any differences as may arise by virtue of the foregoing. I hereby acknowledge receipt of this information. Signature Printed Name Date

8

9 Face Amount Age Monthly Premiums Monthly Premiums $10,000 $15,000 $25,000 $30,000 PAID UP At Attained Age Use the rate sheet to select your face amount and the monthly premium. Locate your age as of the 1 st of the month following the completion of this application and follow across to the appropriate face amount and the applicable tobacco usage column. This will be your monthly bank draft premium and the amount of your initial premium sent with your application. If your requested face amount is not listed on the rate sheet, see attached instructions on calculating your premium

10 Face Amount Age Monthly Premiums $50,000 $75,000 $100,000 $150,000 PAID UP At Attained Age , , , , , , , , Use the rate sheet to select your face amount and the monthly premium. Locate your age as of the 1 st of the month following the completion of this application and follow across to the appropriate face amount and the applicable tobacco usage column. This will be your monthly bank draft premium and the amount of your initial premium sent with your application. If your requested face amount is not listed on the rate sheet, see attached instructions on calculating your premium.

11 Age Monthly Premium per 1,000 for - users Monthly Premium per 1,000 for users Calculating Monthly Premium Instruction for Calculating Premium 17 $0.54 $ Record Face Amount Requested (not less than 18 $0.57 $0.70 $5,000, not greater than $150,000) 19 $0.57 $0.71 Ex. $10,000 $ 20 $0.59 $ $0.60 $ Determine what your age will be on the first of the 22 $0.62 $0.78 month following the completion of the application. 23 $0. $0.81 Ex $0.66 $ $0.68 $ Find your age on the table to the left, follow 26 $0.72 $0.90 across to the appropriate non-tobacco or tobacco 27 $0.75 $0.94 column (whichever applies to you) and record the 28 $0.79 $0.98 monthly premium per 1, $0.83 $1.03 Ex. $4.00 (non-tobacco) $ 30 $0.85 $ $0.91 $ Record the number of units you are purchasing (1 32 $0.97 $1.20 unit = 1,000) ex. $10,000 Face Amount = 10 units 33 $1.02 $1.27 Ex $1.05 $ $1.10 $ Multiply number of units times monthly premium 36 $1.17 $1.49 per 1, $1.25 $1.58 Ex. $40.00 $ 38 $1.32 $ $1.44 $1.80 Policy Fee $ $1.50 $ $1.60 $ Add $3.00 policy fee to your total in step 5 42 $1.69 $2.17 Ex. $43.00 $ 43 $1.79 $ $1.93 $ Total monthly premium for bank draft 45 $2.07 $2.69 equals the total in step 6 46 $2.16 $2.82 Ex. $43.00 $ 47 $2.26 $2.95 If you choose not to complete the bank draft form, there 48 $2.37 $3.09 will be a monthly billing fee added to your premium. $ $2.49 $ $2.58 $ Add $2.00 monthly billing fee if you wish to be 51 $2.69 $3.45 billed monthly direct 52 $2.81 $3.60 Ex. $45.00 $ 53 $2.94 $ $3.08 $ $3.14 $ $3.26 $ $3.45 $ $3.62 $ $3.76 $ $4.00 $ $4.23 $ $4.45 $ $4.66 $ $4.95 $6.48 $5.21 $ $5.56 $ $5.91 $ $6.32 $ $6.76 $ $7.24 $ Total monthly premium for monthly direct bill equals the total in step 8 Ex. $45.00 $ The initial premium sent in with your application will be the bank draft premium in step #7. To obtain premium rates for ages under 17 and over 70, contact Texas Life Insurance Company

12

13 Automatic Bank Draft Form A convenient payment option for you. Three easy steps: 1. Read and complete each item on the Automatic Bank Draft Form. 2. Include either a voided check or deposit slip as required. 3. Mail with your completed application to Texas Life Insurance Company, P.O. Box 830, Waco, TX Please enter all Texas Life policy numbers you want drafted with this authorization: Texas Life will begin drafting your account for the current or any outstanding premiums due immediately. Future drafts will be drawn on the policy date each month, which is typically the 1 st of the month. Please check the appropriate box: [ ] Checking Account Include a check with Void written on it. [ ] Savings Account Include a deposit slip with Void written on it. Work Number ( ) Home Number ( ) Mobile Number ( ) Drafts are submitted to the bank and should clear your account within 2-3 days. If your draft date falls on a weekend or holiday, it will leave our office on the next business day. As a convenience to me, I hereby request and authorize you to pay and charge to my account drafts drawn on my account by and payable to the Texas Life Insurance Company, Waco, Texas provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that your rights in respect to each such draft shall be the same as if it were a draft drawn on you and signed personally by me. The payment of premium under this plan may be discontinued by the Company or the undersigned. You shall be under no obligation to determine the correctness of the amount of any draft drawn under this authority. I further agree that if any such draft be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in forfeiture of insurance. Signature of Bank Account Holder Date

WL TERM * Addition of Coverage IUL IUL Increase Reinstatement *Child/Grandchild Policy not available with TERM

WL TERM * Addition of Coverage IUL IUL Increase Reinstatement *Child/Grandchild Policy not available with TERM Provident Life and Accident Insurance Company 1 Fountain Square Chattanooga, Tennessee 37402 APPLICATION FOR INDIVIDUAL VOLUNTARY LIFE INSURANCE / LONG TERM CARE INSURANCE Child and/or Grandchild* Product

More information

You can relax, knowing your final wishes will be respected.

You can relax, knowing your final wishes will be respected. Memorial Fund You can relax, knowing your final wishes will be respected. Humana Financial Protection Products GNA06XOHH 11/09 MI Memorial Fund Ensure financial peace of mind for you and your family. You

More information

New Coverage Reinstatement Increase of Benefits If Reinstatement or Increase requested, please list GTL policy/certificate number(s) affected:

New Coverage Reinstatement Increase of Benefits If Reinstatement or Increase requested, please list GTL policy/certificate number(s) affected: Application For: Advantage Plus & Lump Sum Cancer Insurance Guarantee Trust Life Insurance Company 1275 Milwaukee Avenue Glenview, IL 60025 (800) 338-7452 Advantage Plus Application for: New Coverage Reinstatement

More information

American General Life Insurance Company Houston, Texas

American General Life Insurance Company Houston, Texas Application for Life Insurance American General Life Insurance Company Houston, Texas Administrative Office: Mail Stop 6-G2, P.O. Box 4373, Houston, TX 77210-9739 Phone: 866-242-2737 Fax: 713-831-3249

More information

Important Information When Considering Portability Coverage

Important Information When Considering Portability Coverage TERM LIFE INSURANCE ELECTION OF PORTABILITY COVERAGE Important Information When Considering Portability Coverage When your group term life insurance coverage ends, either because your employment has terminated

More information

CONTINUATION OF GROUP TERM LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE EMPLOYER INSTRUCTIONS

CONTINUATION OF GROUP TERM LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE EMPLOYER INSTRUCTIONS CONTINUATION OF GROUP TERM LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE EMPLOYER INSTRUCTIONS Employees who have either terminated or lost coverage have 31 days from either their termination

More information

SPECIAL OFFER TO ELIGIBLE FEDERAL GOVERNMENT EMPLOYEES $50,000 Group Term Life Insurance

SPECIAL OFFER TO ELIGIBLE FEDERAL GOVERNMENT EMPLOYEES $50,000 Group Term Life Insurance SPECIAL OFFER TO ELIGIBLE FEDERAL GOVERNMENT EMPLOYEES $50,000 Group Term Life Insurance New York Life Insurance Company 1, one of the largest and most respected life insurance companies in the nation

More information

Golden Solution. Whole Life Insurance. American-Amicable Life Insurance Company of Texas

Golden Solution. Whole Life Insurance. American-Amicable Life Insurance Company of Texas Golden Solution Whole Life Insurance American-Amicable Life Insurance Company of Texas AA9504(10/06) CN6-019 Golden Solution Whole Life Insurance Policy An economical way to free your loved ones from financial

More information

The United American Final Expense Plan 400 Series

The United American Final Expense Plan 400 Series UA INDIVIDUAL WHOLE LIFE Final Expense Plan provides the following insurance features: Permanent whole life insurance coverage issue ages -. Choice of Benefit... Level or Increasing. Increasing Benefit

More information

Tennessee Application for Acci-Flex Insurance This application includes all forms needed to apply for Acci-Flex Insurance.

Tennessee Application for Acci-Flex Insurance This application includes all forms needed to apply for Acci-Flex Insurance. Toll Free: 1-800-276-7619, Ext. 4264 AssureLINK Address: http://assurelink.assurity.com Tennessee Application for Acci-Flex Insurance This application includes all forms needed to apply for Acci-Flex Insurance.

More information

New Coverage Reinstatement Increase of Benefits If Reinstatement or Increase requested, please list GTL policy/certificate number(s) affected:

New Coverage Reinstatement Increase of Benefits If Reinstatement or Increase requested, please list GTL policy/certificate number(s) affected: Application For: Advantage Plus & Lump Sum Cancer Insurance Guarantee Trust Life Insurance Company 1275 Milwaukee Avenue Glenview, IL 60025 (800) 338-7452 Advantage Plus Application for: New Coverage Reinstatement

More information

Email Address Employee ID/Payroll # Employer Name Customer Number Date of Hire (mm/dd/yyyy)

Email Address Employee ID/Payroll # Employer Name Customer Number Date of Hire (mm/dd/yyyy) APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Unum Life Insurance Company of America ( Unum ) 2211 Congress Street Portland, Maine 04122 Application Type: Newly Eligible Late

More information

Senior Whole Life Transmittal

Senior Whole Life Transmittal Senior Whole Life Transmittal Applicant Information: Insured Name: underwriting process. Please advise the best time and place to contact the applicant: We may need to contact the applicant for more information

More information

Home Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone #

Home Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone # Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Application Type: New Enrollee Change to Existing

More information

Group Term Life Insurance Portability Election Form

Group Term Life Insurance Portability Election Form Group Term Life Insurance Portability Election Form If you have been actively employed prior to leaving your employer, and you are not retiring or disabled, you may apply for Group Term Life Insurance

More information

The United States Life Insurance Company in the City of New York

The United States Life Insurance Company in the City of New York Member information (Please print or type) The United States Life Insurance Company in the City of New York APPLICATION FOR GROUP TERM LIFE INSURANCE Home Office: One World Financial Center, 200 Liberty

More information

Application for Life Insurance and Single Premium Annuity

Application for Life Insurance and Single Premium Annuity The Baltimore Life Insurance Company 10075 Red Run Boulevard Owings Mills, MD 21117-4871 800.628.5433 www.baltlife.com Application for Life Insurance and Single Premium Annuity 1. Proposed Insured/Annuitant

More information

The United States Life Insurance Company in the City of New York

The United States Life Insurance Company in the City of New York Applicant information (Please print or type) The United States Life Insurance Company in the City of New York APPLICATION FOR GROUP LEVEL TERM LIFE INSURANCE Home Office: One World Financial Center, 200

More information

Company: 5 Star Life Insurance Company Product Name: Individual Life - Term SERFF Tr Num: FIVE-126096912 State: Arkansas

Company: 5 Star Life Insurance Company Product Name: Individual Life - Term SERFF Tr Num: FIVE-126096912 State: Arkansas TOI: L04I Sub-TOI: L04I.500 Other Filing at a Glance Company: 5 Star Life Insurance Company SERFF Tr Num: FIVE-126096912 State: Arkansas TOI: L04I SERFF Status: Closed-Approved- State Tr Num: 42009 Closed

More information

Group Term Life Insurance

Group Term Life Insurance Professional Pilot & Spouse Group Term Life Insurance No exclusions except suicide which is removed as an exclusion after two years of new coverage or increased coverage. Up to $150,000 in coverage available

More information

Home Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone #

Home Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone # Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Application Type: New Enrollee Change to Existing

More information

Final Expense Whole Life Insurance

Final Expense Whole Life Insurance Final Expense Whole Life Insurance FE 300 1/05 BC Life & Health Insurance Company An important part of your financial strategy Final Expense Whole Life Insurance Rates are Guaranteed and fixed for life

More information

AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224

AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224 AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224 For AHL Home Office use only tes EVIDENCE OF INSURABILITY AND ENROLLMENT FORM Check appropriate

More information

ADA-Sponsored Disability Income Protection Plan Application for Insurance

ADA-Sponsored Disability Income Protection Plan Application for Insurance Members Insurance Plans ADA-Sponsored Disability Income Protection Plan Application for Insurance IPWS15 Read all forms Complete sections 1 thru 9 Mail or Fax ALL completed forms Questions? 866.607.5334

More information

Voluntary Benefits Employee Enrollment and Change Form

Voluntary Benefits Employee Enrollment and Change Form LifeMap Assurance Company TM P.O. Box 1271, MS E-3A Portland, OR 97207-1271 (503) 721-7161 (800) 794-5390 Voluntary Benefits Employee Enrollment and Change Form For residents of Oregon and Washington,

More information

The United States Life Insurance Company in the City of New York

The United States Life Insurance Company in the City of New York Are you a: Member Spouse of a Member Member/Applicant information Please print or type Name (First, Middle, Last) Address The United States Life Insurance Company in the City of New York Application For

More information

Mailing Address: PO Box 696700 San Antonio, TX 78269-6700

Mailing Address: PO Box 696700 San Antonio, TX 78269-6700 Application for Individual Life Insurance Policy Issued by One Moody Plaza, Galveston, TX 77550-7947 Phone Number: 877-862-0759 *APP* page 1 of 6 Mailing Address: PO Box 696700 San Antonio, TX 78269-6700

More information

MONTHLY PREMIUM LIFE AND DISABILITY (SINGLE OR JOINT) CREDIT INSURANCE APPLICATION AND CERTIFICATE (PART A)

MONTHLY PREMIUM LIFE AND DISABILITY (SINGLE OR JOINT) CREDIT INSURANCE APPLICATION AND CERTIFICATE (PART A) MONTHLY PREMIUM LIFE AND DISABILITY (SINGLE OR JOINT) CREDIT INSURANCE APPLICATION AND CERTIFICATE (PART A) SCHEDULE OF CREDIT INSURANCE Credit Union/Primary Beneficiary Educational & Governmental EFCU

More information

1 MEMBER INFORMATION Policy No. MZ0909533H0000A

1 MEMBER INFORMATION Policy No. MZ0909533H0000A Group Term Life Insurance Application Underwritten by Monumental Life Insurance Company, Cedar Rapids, IA Please complete the entire application. Print clearly in dark ink and mail to: Group Term Life

More information

MEMBER S FULL NAME CERTIFICATE # SOCIAL SECURITY NO. MM / DD / YYYY r FEMALE WORK PHONE #

MEMBER S FULL NAME CERTIFICATE # SOCIAL SECURITY NO. MM / DD / YYYY r FEMALE WORK PHONE # NADA Dealer Life Insurance Program and Accidental Death & Dismemberment Insurance (DLIP) Request Form Please print in ink or type all answers initial and date any changes you make Request for Group Insurance

More information

Family Life Insurance Company LBS. Living Benefit Series. Critical Choice LBS. Living Benefit Series. Agent Guide AGT-VL/VCC 0314

Family Life Insurance Company LBS. Living Benefit Series. Critical Choice LBS. Living Benefit Series. Agent Guide AGT-VL/VCC 0314 Family Life Insurance Company LBS Living Benefit Series Critical Choice LBS Living Benefit Series AGT-VL/VCC 0314 Agent Guide Table of Contents Product Specifications - Viva Life Life Insurance Benefit....

More information

Group Term Life Insurance Portability Election Form

Group Term Life Insurance Portability Election Form Group Term Life Insurance Portability Election Form If you have been actively employed prior to leaving your employer, and you are not retiring or disabled, you may apply for Group Term Life Insurance

More information

YOUR GROUP TERM LIFE BENEFITS

YOUR GROUP TERM LIFE BENEFITS YOUR GROUP TERM LIFE BENEFITS FOR EMPLOYEES OF: Indian River County Government CLASS(ES): All Eligible Employees and Retirees EFFECTIVE DATE: October 1, 2014 PUBLICATION DATE: March 2, 2015 NOTICE(S) THIS

More information

NADA Dealer Life Insurance Program and Accidental Death & Dismemberment Simplified Issue Insurance Request Form

NADA Dealer Life Insurance Program and Accidental Death & Dismemberment Simplified Issue Insurance Request Form Request for Group Insurance From New York Life Insurance Company 51 Madison Avenue New York, NY 10010 MEMBER S FULL NAME ADDRESS NADA Dealer Life Insurance Program and Accidental Death & Dismemberment

More information

Check Life Insurance plan(s) desired Life Insurance for Member: $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000

Check Life Insurance plan(s) desired Life Insurance for Member: $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 The United States Life Insurance Company in the City of New York APPLICATION FOR GROUP TERM LIFE INSURANCE Home Office: One World Financial Center, 200 Liberty Street, New York, NY 10281 (Herein called

More information

Application to Continue/Port or Convert Group Insurance

Application to Continue/Port or Convert Group Insurance Application to Continue/Port or Convert Group Insurance Products and financial services provided by American United Life Insurance Company a OneAmerica company One American Square, P.O. Box 7106 Indianapolis,

More information

Voluntary Benefits Employee Enrollment and Change Form

Voluntary Benefits Employee Enrollment and Change Form Voluntary Benefits Employee Enrollment and Change Form LifeMap Assurance Company TM For residents of Oregon and Washington, the definition of a Spouse includes your legal husband or wife or your State

More information

USLIFE Group Voluntary Term Life Insurance Coversheet

USLIFE Group Voluntary Term Life Insurance Coversheet USLIFE Group Voluntary Term Life Insurance Coversheet Applicant Name: (If applicable see next section below) NYSBG Company Name: NYSBG Dues Level: Corporate $60 Current Check attached Corporate Employee

More information

A Special Limited Time Offer on Life Insurance

A Special Limited Time Offer on Life Insurance SWAPA MEMBERS A Special Limited Time Offer on Life Insurance For a limited time; you can now purchase up to $150,000* new coverage with a Special Simplified Issue offer For Members and Spouses of Members.

More information

Simple, Affordable & SAFE!

Simple, Affordable & SAFE! California State Firefighters Employee Welfare Benefits Corporation Simple, Affordable & SAFE! Limited Time Simplified Issue Offer Group Term Life Insurance Application (10-Year Level Term Rate) C2 ReliaStar

More information

A Special Limited Time Offer on Life Insurance

A Special Limited Time Offer on Life Insurance USAPA MEMBERS A Special Limited Time Offer on Life Insurance For a limited time; you can now purchase up to $150,000* new coverage with a Special Simplified Issue offer For Members and Spouses of Members.

More information

Date of Change: If marriage, divorce or birth of a child, please provide copy of document. Social Security Number. Address City State Zip

Date of Change: If marriage, divorce or birth of a child, please provide copy of document. Social Security Number. Address City State Zip Reliance Standard Life Insurance Company Enrollment and Statement of Health Name of Employer Old National Bancorp Policy # and Class # Policy # and Class # Policy # and Class # Policy # and Class # Bill

More information

You can convert your term life insurance.

You can convert your term life insurance. Turning promise into practice TM You can convert your term life insurance. When you terminate employment or insurance eligibility, or you retire, you have options available regarding your current group

More information

CSA FRATERNAL LIFE A Fraternal Benefit Society P.O. Box 249, Lombard, Illinois 60148. Application for Life Insurance

CSA FRATERNAL LIFE A Fraternal Benefit Society P.O. Box 249, Lombard, Illinois 60148. Application for Life Insurance FOUNDED MARCH 4, 1854 Personal Information 1. Full name of Proposed Insured: Lodge Name: CSA FRATERNAL LIFE A Fraternal Benefit Society P.O. Box 249, Lombard, Illinois 60148 Application for Life Insurance

More information

HELP PROVIDE SECURITY AT AFFORDABLE RATES

HELP PROVIDE SECURITY AT AFFORDABLE RATES US Airways Pilots Association (USAPA) Group Term Life Insurance 10-Year Level Premium Administered by: For Association Members and Their Families Issued by ReliaStar Life Insurance Company, a member of

More information

Aetna Individual Medicare Supplement Plan Application Aetna Life Insurance Company PO Box 13547, Pensacola, FL 32591-3547

Aetna Individual Medicare Supplement Plan Application Aetna Life Insurance Company PO Box 13547, Pensacola, FL 32591-3547 Aetna Individual Medicare Supplement Plan Application Aetna Life Insurance Company PO Box 13547, Pensacola, FL 32591-3547 INSTRUCTIONS: To be considered complete, all sections on this form must be filled

More information

Email Address: _ Pre-Disability Earnings: $ City: State: Zip Code: Beneficiary Print full name & relationship to you

Email Address: _ Pre-Disability Earnings: $ City: State: Zip Code: Beneficiary Print full name & relationship to you GROUP DISABILITY INCOME INSURANCE APPLICATION HARTFORD LIFE INSURANCE COMPANY Simsbury, Connecticut 06089 Policyholder: (Participating Organization) Policy No.: Certificate No.: (Leave Blank) AGP-5697

More information

Life Insurance Application

Life Insurance Application Life Insurance Application Product Name Type of Enrollment / Change: (check all that apply) New Application Increase Reinstatement Other ReliaStar Life Insurance Company Home Office: Minneapolis, Minnesota

More information

Columbia Alumni Association (CAA) Group Term Life Insurance Application

Columbia Alumni Association (CAA) Group Term Life Insurance Application Columbia Alumni Association (CAA) Group Term Life Insurance Application Please complete and return this form to: CAA Plan Administrator NEBCO P.O. Box 152501 Irving, TX 75015-2501 1-800-223-1147 Request

More information

Supplemental Life Insurance Benefit Program

Supplemental Life Insurance Benefit Program Supplemental Life Insurance Benefit Program o Ordinary Life (Whole Life Insurance) Paid-Up At 65 o Ordinary Life (Whole Life Insurance) Paid for Life o Term Life Insurance Paid-Up At 65 o Term Life Insurance

More information

NEXT PAGE. Applicant information (Please print or type) Name. Are you a: Member Spouse Domestic Partner* If Spouse/Domestic Partner, Name of Member

NEXT PAGE. Applicant information (Please print or type) Name. Are you a: Member Spouse Domestic Partner* If Spouse/Domestic Partner, Name of Member APPLICATION FOR GROUP LEVEL TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Applicant information (Please print or type)

More information

Credit Limit Requested $ APPLICANT OTHER. NAME (Last - First - Initial) ACCOUNT NUMBER MORTGAGE/RENT OWED TO: NAME AND ADDRESS OF EMPLOYER

Credit Limit Requested $ APPLICANT OTHER. NAME (Last - First - Initial) ACCOUNT NUMBER MORTGAGE/RENT OWED TO: NAME AND ADDRESS OF EMPLOYER Credit Card Application A table that includes required credit card disclosures is on a separate document provided with this Application. To obtain any change in the required information since it was printed,

More information

Continue your Aetna life insurance coverage with this option.

Continue your Aetna life insurance coverage with this option. P.O. Box 24846 Cleveland OH 44124-0846 Group Life Insurance Operations Phone: 1-877-503-3448 Fax: 440-386-2662 Continue your Aetna life insurance coverage with this option. Thank you for your interest

More information

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself

More information

GROUP TERM LIFE INSURANCE EZ OFFER

GROUP TERM LIFE INSURANCE EZ OFFER 7583/7584/1002/43520-S 1. MEMBER INFORMATION: G-11082-0 TO APPLY: Send this completed form with your premium check payable to: ADMINISTRATOR, AIChE GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA

More information

A heart attack doesn t have to be financially devastating, if you re prepared.

A heart attack doesn t have to be financially devastating, if you re prepared. Critical Illness Cash Plan A heart attack doesn t have to be financially devastating, if you re prepared. Humana Financial Protection Products GNA078QHH 1/10 MI Critical Illness Cash Plan Protect yourself

More information

Section A: Applicant Information

Section A: Applicant Information United National Life Insurance Company of America 1275 Milwaukee Avenue - Glenview - Illinois 60025-800-207-8050 Combined Application for Hospital Confinement (U9910) / Hospital Confinement & Home Care

More information

Simple, Affordable & SAFE!

Simple, Affordable & SAFE! The Insurance & Benefits Trust of PORAC Simple, Affordable & SAFE! Group Term Life Insurance Application (10-Year Level Term Rate) Group Term Life Application for 10-Year Level Term Rate Reference to Spouse

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. Life Enrollment & Billing Services 151 Farmington Avenue, RT32 Hartford, CT 06156 Need more information? Log onto www.aetna.com, or call us at 1-800-523-5065 Continue your Aetna life insurance coverage

More information

Civil Service Employees Benefit Association 67182-7. Address City State Zip. Place of Birth Home/Cell Phone # Work Phone # E-mail Address

Civil Service Employees Benefit Association 67182-7. Address City State Zip. Place of Birth Home/Cell Phone # Work Phone # E-mail Address Group Term Life Application for 10-Year or 20-Year Level Term Rate Please complete the entire application. If completing this application in paper format, please print clearly in dark ink and mail to WrightUSA

More information

Application for Critical Care Insurance to: Guarantee Trust Life Insurance Company 1275 Milwaukee Avenue, Glenview, IL 60025 (800) 338-7452

Application for Critical Care Insurance to: Guarantee Trust Life Insurance Company 1275 Milwaukee Avenue, Glenview, IL 60025 (800) 338-7452 Application for Critical Care Insurance to: Guarantee Trust Life Insurance Company 1275 Milwaukee Avenue, Glenview, IL 60025 (800) 338-7452 AGENT NOTE: Please pre-qualify the Applicant (s) with Section

More information

Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company

Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company Application and payment of the first premium must be made within the time limit shown in your certificate

More information

APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company)

APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Member information (Please print or type) Name APTA

More information

VOLUNTARY GROUP TERM LIFE INSURANCE: GUARANTEED ISSUE:

VOLUNTARY GROUP TERM LIFE INSURANCE: GUARANTEED ISSUE: VOLUNTARY GROUP TERM LIFE INSURANCE: This plan offers you and your dependents an excellent opportunity to purchase affordable group term life insurance on a payroll deduction basis. The important plan

More information

Member s Name Social Security # First Middle Last. Member s Address Number Street City State Zip Code. Name and Address of Member s Physician

Member s Name Social Security # First Middle Last. Member s Address Number Street City State Zip Code. Name and Address of Member s Physician Please print or type all information requested Member s Name Social Security # First Middle Last Member s Address Number Street City State Zip Code ASRT Member ID # Home Phone No. Work Phone No. Name and

More information

The United States Life Insurance Company in the City of New York Home Office: One World Financial Center, 200 Liberty Street, New York, New York 10281

The United States Life Insurance Company in the City of New York Home Office: One World Financial Center, 200 Liberty Street, New York, New York 10281 The United States Life Insurance Company in the City of New York Home Office: One World Financial Center, 200 Liberty Street, New York, New York 10281 (Herein called the Company) Application For Group

More information

You never know what can happen on your shift. Is your family financially secure?

You never know what can happen on your shift. Is your family financially secure? You never know what can happen on your shift. Is your family financially secure? Benefits Division Group Life Insurance and Accidental Death Insurance The California State Firefighters Employee Welfare

More information

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself

More information

YOUR GROUP TERM LIFE BENEFITS

YOUR GROUP TERM LIFE BENEFITS Release 11.0.2 YOUR GROUP TERM LIFE BENEFITS FOR EMPLOYEES OF: The School Board of Broward County, Florida CLASS(ES): All Eligible Active Paraprofessionals All Other Eligible Active Employees EFFECTIVE

More information

CONVERSION OF GROUP TERM LIFE INSURANCE. Subject to the terms of the Group Policy, as described in your group insurance certificate:

CONVERSION OF GROUP TERM LIFE INSURANCE. Subject to the terms of the Group Policy, as described in your group insurance certificate: CONVERSION OF GROUP TERM LIFE INSURANCE Subject to the terms of the Group Policy, as described in your group insurance certificate: (1) you may apply for an individual, permanent life insurance policy

More information

The Accelerated Benefits Option ( ABO )

The Accelerated Benefits Option ( ABO ) The Accelerated Benefits Option ( ABO ) Metropolitan Life Insurance Company Group Life Claims Telephone Number: 1-800-638-6420 Please read the following important information before completing the attached

More information

GROUP LIFE INSURANCE CLAIM PACKET (Death)

GROUP LIFE INSURANCE CLAIM PACKET (Death) GROUP LIFE INSURANCE CLAIM PACKET (Death) You Can Help Ensure A Quick Claim Decision All required claim forms must be signed, dated and completed fully and accurately. Provide all supporting documentation

More information

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself

More information

VOLUNTARY GROUP TERM LIFE INSURANCE:

VOLUNTARY GROUP TERM LIFE INSURANCE: VOLUNTARY GROUP TERM LIFE INSURANCE: This plan offers you and your dependents an excellent opportunity to purchase affordable group term life insurance on a payroll deduction basis. The important plan

More information

Accidental Dismemberment Insurance Claim Form

Accidental Dismemberment Insurance Claim Form State of Florida Account Participating Agencies and Departments Payroll Deduction Code 262 Mail To: Cigna P.O. Box 22328 Pittsburgh, PA 15222-0328 1-800-238-2125 Toll Free Claims administered by Cigna

More information

Portability Option for Group Term Life Insurance

Portability Option for Group Term Life Insurance Instructions 1. Employer Please Print 2. Employee Please read the Fraud Notice on the back of the form, before completing. Please Print Portability Option for Group Term Life Insurance Aetna Life Insurance

More information

Enrollment Form for Assurant Cancer and Heart/Stroke Fixed Indemnity Insurance

Enrollment Form for Assurant Cancer and Heart/Stroke Fixed Indemnity Insurance Enrollment Form for Assurant Cancer and Heart/Stroke Fixed Indemnity Insurance PLEASE PRINT IN BLACK INK PERSONS TO BE INSURED Attach a separate sheet, signed and dated, if additional space is needed.

More information

American General Assurance Company

American General Assurance Company American General Assurance Company Proof of Death Claim Claimant s Statement CLAIMANT S STATEMENT: COMPLETE, SIGN AND DATE THIS FORM, THE AUTHORIZATION FOR RELEASE OF INFORMATION AND THE FRAUD STATEMENT.

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. Life Enrollment & Billing Services 151 Farmington Avenue, RT32 Hartford, CT 06156 Need more information? Log onto www.aetna.com, or call us at 1-800-523-5065 Continue your Aetna life insurance coverage

More information

Completing your Personal Health Application New York Applicants

Completing your Personal Health Application New York Applicants Completing your Personal Health Application New York Applicants Purpose These instructions will help you to complete your Personal Health Application. This will help ensure that your application is processed

More information

Health First Insurance, Inc. Medicare Supplement Application 2013

Health First Insurance, Inc. Medicare Supplement Application 2013 6450 US Highway 1, Rockledge, FL 32955 Customer Service: 321.434.4822 Toll-free 1.855.443.4735 TTY relay 1.800.955.8771 Monday through Friday from 8 am to 8 pm, Saturday from 8 am to noon A. General Information

More information

Application for Conversion of Group Term Life Insurance

Application for Conversion of Group Term Life Insurance Application for Conversion of Group Term Life Insurance Aetna Life Insurance Company Application and payment of the first premium must be made within the time limit shown in your certificate or policy.

More information

Southwest Airlines Group Life Portability Insurance Application. Standard Insurance Company INSTRUCTIONS PLEASE READ CAREFULLY

Southwest Airlines Group Life Portability Insurance Application. Standard Insurance Company INSTRUCTIONS PLEASE READ CAREFULLY 920 SW Sixth Avenue Portland OR 97204-1203 800.378.4668 ext. 6785 Group Life Portability Insurance Application INSTRUCTIONS PLEASE READ CAREFULLY Portability Of Insurance You may be eligible to buy portable

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. P.O. Box 24846 Cleveland OH 44124-0846 Group Life Insurance Operations Phone: 1-877-503-3448 Fax: 440-386-2662 Continue your Aetna life insurance coverage with these options. Thank you for your interest

More information

THP Insurance Company, Inc. (THP) Medicare Supplement Insurance Policy Application Ohio and West Virginia

THP Insurance Company, Inc. (THP) Medicare Supplement Insurance Policy Application Ohio and West Virginia Important Notice: Refer to the Guaranteed Issue Guide to determine eligibility for automatic acceptance. If eligible, indicate which situation is applicable in the Guaranteed Issue section. You are not

More information

Application Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage MO, ND

Application Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage MO, ND P.O. Box 3608 Omaha, Nebraska 68103-3608 Application Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage MO, ND THIS APPLICATION MUST BE USED TO WRITE MUTUAL OF OMAHA MEDICARE SUPPLEMENT

More information

USLIFE Group Voluntary Term Life Insurance Coversheet

USLIFE Group Voluntary Term Life Insurance Coversheet USLIFE Group Voluntary Term Life Insurance Coversheet Applicant Name: (If applicable see next section below) NYSBG Company Name: NYSBG Dues Level: Corporate $60 Current Check attached Corporate Employee

More information

Life insurance protection after group coverage ends

Life insurance protection after group coverage ends Group Life Insurance Portability Kit Life insurance protection after group coverage ends LDM-6249 1/14 Don t leave your group life insurance behind. You know how important it is to own life insurance.

More information

Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS

Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS Sponsored by: Xavier University All Full-Time Employees excluding Jesuit Employees Life Benefit Employee Spouse

More information

YOUR GROUP VOLUNTARY TERM LIFE BENEFITS

YOUR GROUP VOLUNTARY TERM LIFE BENEFITS Release 16.2.0 YOUR GROUP VOLUNTARY TERM LIFE BENEFITS FOR EMPLOYEES OF: Evolve Bank & Trust CLASS(ES): All Eligible Employees REVISION EFFECTIVE DATE: January 1, 2015 PUBLICATION DATE: February 4, 2015

More information

Life Insurance Proposal

Life Insurance Proposal Life Insurance Proposal vpl-plus A Voluntary Permanent Life Proposal For the Employees of Presented By Issued By: Metropolitan Life Insurance Company New York, NY 10166 Life Insurance Administrative Office

More information

Monumental Life Insurance Company

Monumental Life Insurance Company Insurance Claim Filing Instructions PROOF OF LOSS CONSISTS OF THE FOLLOWING: 1. A completed and signed Claim form and Attending Physician s Statement. 2. For Hospital/Intensive Care/Hospital Services Coverage

More information

hy should you consider purchasing life insurance protection at your workplace?

hy should you consider purchasing life insurance protection at your workplace? W hy should you consider purchasing life insurance protection at your workplace? Employees find significant value in obtaining non-medical products in their workplace. Many of us lead busy lives and seldom

More information

APPLICATION FOR LIFE INSURANCE - TERM 850 East Anderson Lane Austin, Texas 78752-1602 PART I

APPLICATION FOR LIFE INSURANCE - TERM 850 East Anderson Lane Austin, Texas 78752-1602 PART I PRIMARY INSURED: APPLICATION FOR LIFE INSURANCE - TERM 850 East Anderson Lane Austin, Texas 78752-1602 PART I Full Date of State of Tobacco Use Name Sex Birth Age Birth Tobacco Free Address City State

More information

Long Term Disability Insurance Conversion Plan

Long Term Disability Insurance Conversion Plan Long Term Disability Insurance Conversion Plan The Prudential Insurance Company of America INST-A002112-A Long Term Disability Insurance Conversion Plan If you have any questions regarding the conversion

More information

Orange County Board of County Commissioners Life Insurance Benefits Application Instructions

Orange County Board of County Commissioners Life Insurance Benefits Application Instructions Application Instructions For use in: CA, FL, KY, LA, MD, RI Please Read Carefully The application for life insurance benefits consists of the forms included in this packet, as well as the additional information

More information

Texas Application for SecureHorizons Medicare Supplement Plan

Texas Application for SecureHorizons Medicare Supplement Plan Texas Application for SecureHorizons Medicare Supplement Plan Eligibility: To be eligible for this Medicare supplement plan you must be: n Enrolled under Federal Medicare Hospital Insurance (Part A) and

More information

Application for Life Insurance American Memorial Life Insurance Company P.O. Box 2730 Rapid City, SD 57709

Application for Life Insurance American Memorial Life Insurance Company P.O. Box 2730 Rapid City, SD 57709 Application for Life Insurance American Memorial Life Insurance Company P.O. Box 2730 Rapid City, SD 57709 HOME OFFICE USE ONLY # Any person who knowingly presents a false or fraudulent claim for payment

More information

MCG, Inc. dba Georgia Regents Medical Center Life Insurance Benefits Application Instructions

MCG, Inc. dba Georgia Regents Medical Center Life Insurance Benefits Application Instructions Application Instructions Please Read Carefully The application for life insurance benefits consists of the forms included in this packet, as well as the additional information noted under item 1 below.

More information

The Prudential Insurance Company of America

The Prudential Insurance Company of America Basic Term Life Insurance Accidental Death and Dismemberment Insurance Optional Term Life Insurance Dependent Term Life Insurance Optional Accidental Death and Dismemberment Insurance The Prudential Insurance

More information