GROUP TERM LIFE INSURANCE APPLICATION PACKAGE

Transcription

1 GROUP TERM LIFE INSURANCE APPLICATION PACKAGE How to Apply: 1. Complete the entire application form and return to administrator: * If you wish to request automatic withdrawal of premium payments from your checking or savings account, complete the ACH form included in this package. The Bar Plan Insurance Agency, Inc Hidden Creek Court St. Louis, MO Contact Information: Annette R. Hilyard DIRECT DIAL , x126 TOLL FREE FAX 3. Underwriting Your Application: Some applicants may be required to have a medical exam to apply for coverage. For more information, please consult your plan administrator.

2 Group Term Life Insurance for The Missouri Bar For Missouri Bar Members, Their Families and Their Employees HELP SECURE YOUR FAMILY S FUTURE WITH CAREFUL PLANNING thing can replace the loss of a loved one, but carefully chosen life insurance coverage can ease the financial stress that death brings to a family. It can help provide the funds your spouse and dependents need for a secure, comfortable future. By planning ahead, you can ensure that your beneficiaries will have the money necessary to: Maintain the standard of living you want for them. Protect your home and other assets. Pay for education, child care and household expenses. Cover funeral and probate costs, taxes, debts and other obligations. Invest for income and opportunities in coming years. Professionals like you take your responsibilities seriously. You want the best for your family. That s why so many successful professionals choose the ReliaStar Life Insurance Company Association Group Term Life Insurance plan. FEATURES OF THE PLAN Member Coverage The plan provides eligible members with group term life insurance protection in the amount you select, from $10,000 to $1,000,000 in $5,000 increments. This group coverage is available to you as a member of The Missouri Bar. Administrative costs for group coverage are low, so you can save in premium costs and enjoy the benefits of the plan. Spouse, Child and Employee Coverage Spouses can apply for coverage amounts of $10,000 to $500,000 in $5,000 increments, regardless of whether the member is insured or not. Employees of Missouri Bar members and their spouses can apply for up to $250,000 in $5,000 increments. Employee spouse coverage cannot exceed the employee's and terminates when employee's coverage terminates. Coverage of $5,000, $10,000, $15,000 or $20,000 is also available for your children at a rate of $6.90 per $5,000 semiannually. One premium covers all eligible children, ages 15 days to 21 years, or to age 25 if a fulltime student. Children ages 15 days to six months are eligible for $1,000, $2,000, $3,000 or $4,000 respectively. Eligibility for This Plan Missouri Bar members and their employees under age 60 who are actively at work are eligible for coverage. Spouses of members and spouses of members' employees are eligible to apply for coverage to age 60 if the spouse is able to conduct the normal activities of a person of like age and gender, and is in good health. Pay Premiums if You're Disabled If you become totally disabled before age 70, you may keep your coverage, subject to policy provisions, without paying premiums. (Employee spouse not eligible.) Coverage to Age 75 Coverage continues for Missouri Bar members and their spouses to age 75 and then terminates. At age 75, you may convert to a whole life policy without proof of good health. In compliance with age discrimination laws, employees' coverage will continue at a reduced level beyond age 75 if they are actively at work. Coverage is subject to renewal by the policyholder and timely premium payment. Protection for Accidental Death and Dismemberment (AD&D) The unexpected financial shock of an accident can be devastating to a family. That s why this plan offers a special accident safeguard. The AD&D benefit pays your beneficiary the amount of coverage you select if you die in a covered accident, to a maximum of $500,000. In addition, if you are dismembered or lose your sight in a covered accident, you will receive a portion of your coverage, depending on the severity of the accident. AD&D coverage costs $1.70 per $10,000 semiannually. To take advantage of this offer, simply check the box on the application form. (Employee spouse not eligible.) Individual Life Policy Conversion Option If a covered person later becomes ineligible for this group coverage, conversion to an individual policy is allowed without proof of good health. Issued by ReliaStar Life Insurance Company, a member of the ING family of Companies. Your future. Made easier.

3 GROUP TERM LIFE INSURANCE FOR THE MISSOURI BAR ADDITIONAL BENEFITS Guaranteed Issue New Missouri Bar members under age 50 who apply for coverage within 90 days of becoming members may apply for $50,000 of coverage without proof of good health. $10,000 is available for new members age A Pay-Out Option During Your Lifetime If you are terminally ill and have a life expectancy of twelve months or less, you can receive a portion of your death benefit before dying. You can receive a payment of up to 50 percent of your coverage, from a minimum of $5,000 to a maximum or $100,000. All remaining insurance benefits will be paid to your beneficiary when you die. Ownership Transfer Available The provisions of this group policy allow you to transfer ownership of coverage to your spouse, business partner, professional corporation or a trust. Transfer of ownership could result in a tax advantage for you. Contact your tax advisor for details. SEMI-ANNUAL RATES PER $10,000 OF COVERAGE Semi-Annual Costs for n-tobacco Users $10,000 to $100,000 to $200,000 to $300,000 to $400,000 to Age $ $199,999 $299,999 $399,999 $1,000,000 Under 30 $3.93 $3.60 $3.47 $3.32 $ * Semi-Annual Costs for Tobacco Users $10,000 to $100,000 to $200,000 to $300,000 to $400,000 to Age $ $199,999 $299,999 $399,999 $1,000,000 Under 30 $5.14 $4.70 $4.51 $4.32 $ * * Member and spouse coverage reduces to the lesser of 50% or $50,000 at age 70, and terminates at age 75. The reduced amount has the conversion option. Premium billed for ages will be based on your reduced amount of insurance. Premiums are based on your age and increase as you enter a new age bracket. Your age is your age on the plan anniversary date. All rates shown in the brochure are guaranteed through December 31, The Bar Plan Insurance Agency, Inc Hidden Creek Court St. Louis, MO Phone: (800) Fax: (314) HOW TO APPLY Complete the entire application form: Simply complete the application form and return it to: The Bar Plan Insurance Agency, Inc., 1717 Hidden Creek Court, St. Louis, MO Use a separate form for your spouse and employees. Contact Administrator: Contact your plan administrator for additional forms, if necessary. Underwriting Your Application: Some applicants may be required to have a medical exam to apply for coverage. For more information on medical requirements, please consult your plan administrator. Products that span the financial spectrum. Distribution through customers channel of choice. Services to help manage financial, benefits, and retirement programs. ING Association Sales offers a broad array of traditional group insurance products, voluntary benefits and value-added services to meet the financial needs of association members and their employees. It offers insurance programs to more than 250 professional associations and their members nationwide. Insurance products provided by ReliaStar Life Insurance Company, which is a wholly-owned indirect subsidiary of ING Groep N.V., an Amsterdam-based global leader in integrated financial services, providing banking, insurance and asset management businesses in more than 50 countries worldwide. Each insurer is solely responsible for the financial obligations under the policies or contracts it issues. This brochure is for summary purposes only. For a complete description of benefits and limitations, please read your Insurance Certificate. Policy Form: LP04GP 2009 ING rth America Insurance Corporation ART.AB.P.GL (12-09)

4 Group Term Life Application Please complete the entire application. The proposed insured should fill out this application. Please print clearly in dark ink and mail to The Bar Plan Insurance Agency, Inc., 1717 Hidden Creek Court, St. Louis, MO Tell us about yourself Name of Association The Missouri Bar You are applying as: Association Member Spouse of Member Employee of Member Your Name (last, first, middle) Name of Member Female Male Date of Birth Height Weight Social Security Number GL Address City State ZIP Home Phone Work Phone Address Owner (if other than yourself.) The owner controls all rights to the certificate. Name Address City State ZIP If you are a new applicant, indicate initial amount of coverage applied for: If you are increasing coverage, indicate amount of additional coverage applied for with this application: Check box(es) to purchase: $ Accidental Death & Dismemberment $ in $5,000 increments $ in $5,000 increments Dependent Child: $5,000 $10,000 $15,000 $20,000 Youngest child DOB (For children 15 days to 6 months of age see brochure for eligible coverage amounts.) 2 Have you used tobacco products of any kind in the last 12 months? Are you currently working at least 30 hours per week at your regular occupation and place of business? Will any of the insurance proposed in this application replace, discontinue or change any life insurance or annuities now in force? If yes, please explain: Beneficiary information List one or more beneficiaries below. List the percent each will receive. The total must equal 100 percent. Beneficiary for dependent coverage will be the certificate holder. Name Address Relationship Percent ReliaStar Life Insurance Company Box 20 Minneapolis, MN Please complete and sign back of application. GTLIFEUW04-MO E-Ship: /18/2007

5 3 Provide us with this health information a.) Have you, for any condition during the past 12 months, consulted a physician/health practitioner, received surgical or medical care, or taken prescribed medication? b.) Have you ever been diagnosed or treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), disorders of the immune system or tested positive for antibodies to the HIV virus? c.) Have you ever been diagnosed with or been treated for: disease or disorder of heart; lungs; nervous/mental system (including anxiety and depression); liver; kidneys; stomach; colon or genito-urinary system; stroke; high blood pressure; cancer or tumor; diabetes; or arthritis? d.) In the past 10 years have you sought help or received counseling or treatment for alcohol or drug use, or are you currently using illegal drugs? If you answered yes to any of the questions above, please give full details below. Attach additional sheets if needed. Q# Name Conditions/illness/treatment Date(s) of Physician/health practitioner s name treatment and complete mailing address 4 Read f.) List the name and address of your regular physician/health practitioner and the date you last consulted him or her: this information carefully, then sign and date below To the best of my knowledge and belief, the information I ve provided is complete and correct. I understand and agree that no coverage shall take effect unless this application is approved by ReliaStar Life Insurance Company and the first premium is paid in my lifetime. I understand my coverage begins on the effective date assigned by ReliaStar Life. Authorization and Acknowledgment Please read and sign below. For underwriting and claim purposes, I give my permission to: Any physician, or any other medical practitioner, hospital, clinic, other medical or medically related facility, insurance or reinsurance company, Medical Information Bureau, Inc. (MIB), Department of Motor Vehicle Records, employer or any other organization or person to give ReliaStar Life Insurance Company (ReliaStar Life) or its authorized representative (including ChoicePoint or any consumer reporting agency) acting on its behalf ALL INFORMATION on my behalf (except as limited below), including findings on medical care, psychiatric or psychological care or examination, surgery or any non-medical information, including motor vehicle records, as they apply to any person who is to be covered. I give my permission to ReliaStar Life to get consumer or investigative consumer reports about the same persons. I give my permission to ReliaStar Life to get any and all such information for the purposes described in this form. I specifically consent to the redisclosure of such information as set forth in this form. I know that my medical records, including any alcohol or drug abuse information, may be protected by Federal Regulations 42 CFR Part 2. I may revoke this authorization as it applies to any information protected by 42 CFR Part 2 at any time, but not to the extent action has been taken in reliance on it. I understand all or part of the information obtained by this authorization may be communicated between ReliaStar Life its affiliates and may be sent to MIB. This information may be made available to any ReliaStar Life affiliate, reinsurer, employer, or contractor who processes transactions that concern any coverage I may have requested or have with ReliaStar Life or its affiliates. I understand that my additional written consent will be required before any information described above is given, sold, transferred, or, in any way, relayed to another party not previously specified (unless otherwise provided by law). My additional consent must be provided on a form that states the new use of the information or why another party needs it. I know that I have the right to get a copy of this form. A photocopy of this form will be as valid as the original. As it relates to the incontestability clause, this form will be valid for 30 months from the date shown below or for two years from the date coverage is made effective, whichever is earlier. I acknowledge that I have been given ReliaStar Life s Consumer Privacy tice. Any person who knowingly and with intent to defraud, submits an application or files a statement of claim containing any materially false or misleading information, commits a fraudulent act, which is a crime. Your Signature Date Signed Signature of Owner (if other than yourself) Date Signed GTLIFEUW04-MO E-Ship: /18/2007

6 Automatic Clearing House (ACH) Automatic Payment is an easy and convenient way to make your Missouri Bar Group Term Life Insurance payments. By signing up for Automatic Pay, you will: Free yourself of monthly check writing Stop worrying about checks being lost or delayed in the mail Have a record of payments on your bank statements Save postage and cost of checks Make payments even when you re on vacation or out of town To enroll in the automatic payment program, just fill out the information below and return with your application. I would like to enroll in the Automatic Payment Plan Name Street Address City State Zip Checking Savings Account # Please Attach a Voided Check from Your Account I authorize The Bar Plan Insurance Agency to charge my monthly Missouri Bar Group Term Life Insurance payment to my bank account number shown above. I understand that the funds will be withdrawn on the first business day of each month and that it is my responsibility to ensure funds are in my account at that time. I understand that if my payment amount changes whether by an increase or decrease in premium owed, I will receive notice from The Bar Plan and they will withdraw the new amount on the first of the following month. This authority will remain in effect until I instruct The Bar Plan to cancel or I am no longer eligible for the coverage. I acknowledge that the origination of ACH transactions to my account must comply with the provision of U.S. law. Signature Date

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8 PRIVACY STATEMENT of The Bar Plan Group of Companies* In the course of doing business with The Bar Plan Group of Companies (TBP), you provide nonpublic personal information to TBP. This Privacy Statement provides information about the types of information collected and TBP s policy with respect to the use of that information. This statement is being provided in compliance with the Gramm-Leach-Bliley Act (Pub. Law ). Information Collected We collect only the information necessary to consistently deliver responsive products and services to you. This service may include advising you of other products and services that TBP offers. The information collected may include: Information we receive from you on applications or other forms; Information about your transactions with us, our affiliates or others; Information about your transactions with nonaffiliated third parties; and Information from a consumer reporting agency. Affiliated Companies in TBP The Bar Plan Mutual Insurance Company (Lawyers Professional Liability Insurance) The Bar Plan Surety and Fidelity Company (Surety and Fidelity Insurance) The Bar Plan Insurance Agency, Inc. (Insurance Agency) TBP Holding Company (A Holding Company) Use of Information Collected TBP does not sell information about current or former customers to third parties. We also do not share such information, except when it is required to complete transactions at your request, or to provide you with information that may be relevant to your insurance needs. We may contract with non-affiliated third parties to perform services for TBP. When necessary, we will only disclose the information necessary for the third party to carry out its agreed responsibilities. We require these non-affiliated third parties to treat your personal information as confidential. We will not disclose any information regarding your assets, liabilities, income or information from a consumer reporting agency with any affiliate or nonaffiliated third party unless you tell us to do so, or unless we tell you before-hand and give you a chance to say no. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as stated above or as otherwise permitted by law. Protection of Information Collected We restrict access to nonpublic personal information about you to those employees who need to know that information to provide products or services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. * * * *Following is a list of The Bar Plan Group of Companies that this notice applies to, as of January 1, 2004: The Bar Plan Mutual Insurance Company The Bar Plan Insurance Agency, Inc. The Bar Plan Surety and Fidelity Company TBP Holding Company