Greek Catholic Union of the U.S.A Tuscarawas Road, Beaver, PA Phone: FAX: Authorization
|
|
- Bruce Walker
- 8 years ago
- Views:
Transcription
1
2
3
4
5 Greek Catholic Union of the U.S.A. A Fraternal Benefit Society 5400 Tuscarawas Road, Beaver, PA Phone: FAX: Authorization For Blood Testing and Disclosure of Results I do hereby authorize blood to be drawn from me for laboratory tests. I understand that: 1. The tests performed will be those required by the Insurer to determine my eligibility for the insurance I have applied for; 2. I have the right to refuse to have blood drawn and that, in such event, the Insurer will decline to accept my application; and 3. The tests preformed shall include, but are not limited to, tests for: I further authorize: a. Cholesterol and related blood lipids; glucose; liver or kidney disorder; or the presence of medication, drugs, nicotine or metabolites; and b. Immune disorders; or T-Helper to T-Suppressor ratio with total T-cell count. 1. The laboratory to disclose the test results to the Insurer; 2. The Insurer to disclosed the test results, including any abnormal results, to its reinsurer, provided such reinsurer is involved in the determination of my eligibility for insurance; and 3. The Insurer to make a brief, coded report to the Medical Information Bureau (MIB) in the manner described in the MIB Notice I received as a part of my application process. I understand that the test results will be confidential. No one will have access the test results except: as I have authorized; as I may later authorize; or, as may be required by law. Name of Proposed Insured (Please Print) Address Signature of Proposed Insured Witness (Signature) (Printed Name) Date GCUBloodAuth092011
6 GREEK CATHOLIC UNION OF THE USA (Herein called GCU) 5400 Tuscarawas Road, Beaver, PA (724) A Fraternal Benefit Society Addendum to Life Insurance Application Form AL-0494 A. The following questions are added as an addendum to the application form noted above and are part of the application: 1. Does any person named as Beneficiary or Contingent Beneficiary lack an insurable interest* in the person to be insured? Yes No If yes, please explain 2. Is any portion of the premium on the policy applied for, to be paid in whole or in part through an assumption; and/or forgiveness of a loan used to fund premiums? Yes No If yes, please explain *Insurable interest -A connection by blood of the beneficiary to the insured or an economic connection under which the beneficiary stands to suffer financial loss by reason the death of the insured. B. Greek Catholic Union of the USA is licensed to do business in the state of Ohio. As a tax exempt entity, Fraternal Benefit Societies are not included in the Ohio Guaranty Association. This means that Fraternal Benefit Societies cannot be assessed for the insolvency of other life insurers or other Fraternal Benefit Societies. By law, a Fraternal Benefit Society is responsible for its own solvency. If there is an impairment of reserves, a certificate holder may be assessed a proportional share of the impairment. This process is described in the certificates issued by the Society. C. Those portions of the Notice to Proposed Insured and/or the authorization on application, Form AL-0494 which make reference to Medical Information Bureau or MIB are deleted in their entirety and replaced with the following wording which will amend part of the application Form AL-0494 through inclusion as part of amendment STOLI-2. Notice to Proposed Insured: I understand that information regarding insurability will be treated as confidential. The Greek Catholic Union of the USA or its reinsurer(s), may, however make a brief report thereon to MIB, Inc., a not for profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. Should I apply to another MIB member company for life or health insurance coverage or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information it may have about you in its files. The Greek Catholic STOLI-2 Page 1
7 Union of the USA or its reinsurer(s) may also release information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. (Medical information will be disclosed to my attending physician only). If you question accuracy of the information in the MIB s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB s information office is: 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts D. I hereby authorize any licensed physician, medical practitioner, hospital, clinic or medical or medically related facility, insurance company, MIB Inc., ( MIB ) or other organization, institution or person, that has any records or knowledge of me or my health, to give the Greek Catholic Union of the USA, or its representatives, including Equifax or bearer, or reinsurer, any such information. The Greek Catholic Union of the USA may disclose such information to its reinsurer(s) or MIB, Inc. This authorization is valid for 30 months after the date shown below. Signed at this day of, 20 Signature of Proposed Insured Signature of Owner (Parent or Guardian) STOLI-2 Page 2
8 AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE MEDICAL INFORMATION I hereby authorize any: medical practitioner, physician, hospital, clinic, pharmacy benefit manager, or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, government agency, group policy holder, employer, benefit plan administration, the MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), or to any agent, attorney, consumer reporting agency or independent administration, including medical record retrieval services or pharmaceutical services, acting on THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), or its reinsurers behalf, information concerning advice, care, or treatment sought by or provided to me and/or any other applicant for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, pharmacy prescription drugs, and/or drug, alcohol or tobacco usage of the applicant(s) THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU). It is understood that THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU) underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I understand that after this information is disclosed, the recipient may re-disclose it resulting in loss of protection by federal regulations. I understand that: such information will be used by THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU) for underwriting and insurability determinations; I may refuse to sign this authorization and that my refusal to sign will affect my ability to obtain life insurance coverage; A picture copy or photocopy of this authorization shall be as valid as the original; and Any authorized representative of the proposed insured is entitled to receive a copy of this authorization upon request. This authorization is valid from the date signed for a duration of 24 months. I understand I may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Life Underwriting Department of THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), 5400 Tuscarawas Road, Beaver, PA I may inspect or copy any information used or disclosed under this authorization, if signed. Date Proposed Insured (Please print) Signature of Proposed Insured (or parent if Proposed Insured is under age 18) Birthdate Additional Proposed Insured (Please print) Signature of Additional Person Proposed for Insurance Birthdate Personal Representative designated by signature above is hereby authorized to execute this instrument based on: Power of attorney, guardian-in-fact, guardian, payee, representative, other (Circle one) HIPPA A
Greek Catholic Union of the U.S.A. 5400 Tuscarawas Road, Beaver, PA 15009 Phone: 724-495-3400 FAX: 724-495-3421. Authorization
Greek Catholic Union of the U.S.A. A Fraternal Benefit Society 5400 Tuscarawas Road, Beaver, PA 15009 Phone: 724-495-3400 FAX: 724-495-3421 Authorization For Blood Testing and Disclosure of Results I do
More informationPhone: Hm( ) Work: ( )
EZ Enrollment Application to American National Life Insurance Company of Texas Galveston, Texas Print in Black New Reinstatement-Existing # Change -Existing # 1. I, as an association member, apply for:
More informationAPPLICATION 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 informationAPPLICATION 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 informationMember 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 informationYou may apply for up to $2,000,000. Your spouse may apply for up to $1,000,000
ASSOCIATION LIFE INSURANCE THROUGH THE ISBA INSURANCE AGENCY Thank you for your interest in the ISBA s Group Term Life Insurance product. Per your request, please find enclosed the following: A product
More informationNEW BUSINESS MEMO GUARANTEED ISSUE WHOLE LIFE
NEW BUSINESS MEMO GUARANTEED ISSUE WHOLE LIFE Regular Mail: United Home Life Insurance Company P.O. Box 7192 Indianapolis, IN 46207-7192 FAX Number: 317-692-7711 Telephone: 800-428-3001 Overnight Mail:
More informationAPPLICATION FOR INSURANCE. 1. Full Name (print) Phone Number: 2. (Address) (City) (State) (Zip)
APPLICATION FOR INSURANCE FIRST CATHOLIC SLOVAK UNION OF THE U.S.A AND CANADA ( A Fraternal Benefit Society) 6611 Rockside Road, Independence, Ohio 44131 2398 216 642 9406 www.fcsu.com Is applicant a member
More informationVOLUNTARY GROUP TERM LIFE INSURANCE Application to: American Family Life Assurance Company of Columbus (AFLAC) Worldwide Headquarters
VOLUNTARY GROUP TERM LIFE INSURANCE Application to: American Family Life Assurance Company of Columbus (AFLAC) Worldwide Headquarters Policy Number Columbus, Georgia 31999 Please Print In Black Ink - To
More informationThe 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 informationUSLIFE 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 informationMailing 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 informationNEXT 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 informationAPPLICATION 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 informationUnderwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) APPLICATION for Group Term Life Insurance
Gynecologists Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) APPLICATION for Group Term Life Insurance The American College of Obstetricians
More informationACCIDENTAL DEATH -NEW BUSINESS MEMO WHOLE LIFE PROTECTOR APPLICATION
Telephone: 800-428-3001 ACCIDENTAL DEATH -NEW BUSINESS MEMO WHOLE LIFE PROTECTOR APPLICATION Regular Mail: Overnight Mail: P.O. Box 7192 225 South East St Indianapolis, IN 46207-7192 Indianapolis, IN 46202
More informationApplication 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 informationThe 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 informationWelcome to Credit Union-Approved 50-Plus Term Life Insurance
Welcome to Credit Union-Approved 50-Plus Term Life Insurance Print out this kit for everything you need to decide if this coverage is right for you: 50-Plus Term Life Insurance introduction and highlights
More informationThe 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 information1 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 informationCheck 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 informationApplication for Life Insurance
National Slovak Society Of the United States of America A Fraternal Benefit Society 351 Valley Brook Road McMurray, PA 15317-3337 Phone (724) 731-0094 Fax (724) 731-0146 www.nsslife.org Application for
More informationThe 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 informationFinal 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 informationSimple, 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 informationADA-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 informationUSLIFE 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 informationVOLUNTARY 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 informationSenior 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 informationHARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut 06089 Section 1
GROUP LIFE INSURANCE APPLICATION HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut 06089 Section 1 Policyholder: American College of Emergency Physicians Policy No.: AGL-1905 Certificate
More informationAddress City State ZIP Code. 2) Date of Birth: - -
Use this form to start the term insurance application process. Understand that completion of this form does not constitute an offer of insurance. Insurance will not take effect until the policy is delivered
More informationA 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 informationSection 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 informationCivil 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 informationA 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 informationAPPLICATION FOR TERM CONVERSION (with Riders or Extra Benefits) OR POLICY REISSUE
72954101 APPLICATION FOR TERM CONVERSION (with Riders or Extra Benefits) OR POLICY REISSUE Liberty National Life Insurance Company P.O. Box 2612 Birmingham, AL 35202 A Nebraska Stock Company PART 1 Section
More informationK L M N Basic, including 100% Part B coinsurance. Basic, including 100% Part B. coinsurance. Skilled Nursing Facility coinsurance.
Forethought Life Insurance Company Administrative Office P.O. Box 14659, Clearwater, FL 33766-4659 (877) 492-5870 Outline of Medicare Supplement Coverage Cover Page Benefit Plans A, C, F, G and N Benefit
More informationVOLUNTARY 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 informationAutomatic Bank Draft--Starting day of each month (not available on the 29th, 30th and 31st) Automatic Premium Loan (APL) is active unless checked
POLICY NUMBER PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LIMITED Pacific Guardian Tower 1440 Kapiolani Boulevard, Suite 1700 Honolulu, Hawaii 96814-3698 (808) 955-2236 PROPOSED INSURED S INFORMATION Full
More informationEZ Enrollment Application to American National Life Insurance Company of Texas (ANTEX) Home Office Galveston,Texas
EZ Enrollment Application to American National Life Insurance Company of Texas (ANTEX) Home Office Galveston,Texas Print in Black New Reinstatement-Existing # Change-Existing # 1. Special Requests: Mail
More informationACCIDENT INSURANCE CLAIM
ACCIDENT INSURANCE CLAIM Employee Benefits ReliaStar Life Insurance Company A member of the ING family of companies Administered by: Your future. Made easier. SM Key Benefit Administrators, Inc., PO Box
More informationYou 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 informationGROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS BY A THIRD PARTY ADMINISTRATOR
GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS BY A THIRD PARTY ADMINISTRATOR PLEASE SUBMIT THE FOLLOWING: INSTRUCTIONS FOR FILING A LIFE INSURANCE CLAIM 1. THE CLAIM
More informationU.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY #
U.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY # POLICY OWNER HOME PHONE INSURED HEIGHT WEIGHT DATE OF BIRTH SOCIAL SECURITY NO. WORK PHONE PLEASE NOTE ANY CHANGE OF
More informationSCHEDULE OF PREMIUM AND BENEFITS EFFECTIVE DATE GROUP POLICYHOLDER GROUP POLICY NO. APPLICATION NO. INPAP
AMERICAN MODERN LIFE INSURANCE COMPANY A Stock Company 7000 Midland Blvd, Amelia, OH 45102-2607 SCHEDULE OF PREMIUM AND BENEFITS EFFECTIVE DATE GROUP POLICYHOLDER GROUP POLICY NO. APPLICATION NO. INPAP
More informationU.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY #
U.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY # POLICY OWNER HOME PHONE INSURED HEIGHT WEIGHT DATE OF BIRTH SOCIAL SECURITY NO. WORK PHONE PLEASE NOTE ANY CHANGE OF
More informationIdaho 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 Idaho Application for Acci-Flex Insurance This application includes all forms needed to apply for Acci-Flex Insurance.
More informationApplication for Single Premium Whole Life Insurance
Royal Neighbors of America Application for Single Premium Whole Life Insurance www.royalneighbors.org Rock Island, Home Office 230 16th St., Rock Island, IL 61201 (800) 627-4762 This page is intentionally
More informationHow To Get A Critical Illness Insurance Plan In Hawthorpe
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 informationNEW BUSINESS MEMO WHOLE LIFE
NEW BUSINESS MEMO WHOLE LIFE Regular Mail: P.O. Box 7192 Indianapolis, IN 46207-7192 FAX Number: 317-692-7711 Telephone: 800-428-3001 Overnight Mail: 225 South East St Indianapolis, IN 46202 # pages including
More informationSimple, 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 informationTennessee 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 informationApplication 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 informationColumbia 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 informationGROUP DISABILITY INCOME INSURANCE FOR PHYSICIANS PLAN DETAILS
GROUP DISABILITY INCOME INSURANCE FOR PHYSICIANS PLAN DETAILS Underwritten by New York Life Insurance Company Administered by: THE HILB GROUP OF NEW YORK, LLC PO Box 5671, Bay Shore, NY 11706 (800)-556-1700
More informationINDIVIDUAL LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM
INDIVIDUAL LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM On behalf of Boston Mutual Life Insurance Company, please accept our sincere condolences
More informationCompletion of a fact finder will accelerate the underwriting process
QUICK FACT-FINDER TOOLS All personal information protected by HIPPA regulations (see HIPPA form attached with supplemental forms) Completion of a fact finder will accelerate the underwriting process Name:
More informationA Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form
A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. So that we can
More informationApplication for Individual Health Insurance
1 of 6 New policy: Policy reinstatement: Dependent addition: Change of plan/option: I. Applicant information 1. Last Name(s): 2. First Name: 3. Middle Initial: 4. Address: 5. City: 6. State: 9. Phone Number
More informationAGENT S INSTRUCTIONS. Auto-Owners Life Insurance Company
The process is simple and the application consists of only a few questions. Once completed, the agent faxes three pages to ExamOne. The process When is ExamOne simple and receives the application the application,
More informationMEMBER 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 informationTerm Life Insurance Plan
Term Life Insurance Plan Your association is pleased to endorse Term Life Insurance available to you and your spouse. You can choose the coverage amount to fit your needs. Term Life is an affordable way
More informationA Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form
A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. So that we can
More informationMontana 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 Montana Application for Acci-Flex Insurance This application includes all forms needed to apply for Acci-Flex Insurance.
More informationCalifornia Life Settlement Qualification Form
PERSONAL INFORMATION California Life Settlement Qualification Form First Insured Name: SS # Current Address: City: State: Zip: Date of Birth: Driver s License Number: State: Expiration: Second Insured
More informationApplication 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 informationGroup Term Life Insurance Plan
STATE BAR OF WISCONSIN Group Term Life Insurance Plan Affordable group term life insurance, approved by the State Bar of Wisconsin as a benefit of your membership. 0232921 STATE BAR OF WISCONSIN Group
More informationSECURE SENIOR ADVANTAGE
ALABAMA ALABAMA / / COLORADO / / / GEORGIA / GEORGIA /// LOUISIANA SOUTH / SOUTH CAROLINA / SOUTH / CAROLINA / TEXAS / / TEXAS / TEXAS Application for SECURE SENIOR ADVANTAGE SECURITY WHOLE LIFE INSURANCE
More information- - First Name MI Last Name Gender Phone Number. Street Address City State Zip Code E-mail Address
Application for Life Insurance for the SERB NATIONAL FEDERATION (Herein called the SNF) Is the proposed Applicant a member of the SNF? Yes No. If No, applicant must apply for membership. Lodge # A. Proposed
More information... ... Guide to Group 10-Year Level Term Life Insurance N S P E ...
Guide to Group 10-Year Level Term Life Insurance Answers to Your Questions About Group 10-Year Level Term Life Insurance What exactly do you mean by 10-Year Level Term? When you buy Level Term life insurance,
More informationINTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE
INTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE FOR U.S. Dollar Term Life Insurance for use when there is an international insurable interest involved. USES Employees of Foreign National Firms International
More informationAccident Claim Filing Instructions
Accident Claim Filing Instructions Page One Filing Instructions Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which includes the date of service,
More informationSimplified Critical Illness
Toll-free Number: (800) 276-7619, Extension 4264 AssureLINK Address: http://assurelink.assurity.com Simplified Critical Illness Thank you for your interest in writing business with Assurity Life Insurance
More information10% 31.5% ASCE Group Term Life Insurance. Rate Decrease as of September 1, 2014 ASCE MEMBER INSURANCE PROGRAM
ASCE MEMBER INSURANCE PROGRAM ASCE Group Term Life Insurance 10% Rate Decrease as of September 1, 2014 Student loans. New car. Mortgage. Childcare. Bank loans. Do you have these financial responsibilities?
More informationNew 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 informationDisability insurance endorsed by the State Bar of Texas Insurance Trust as a benefit of your membership. 0257930-00001-00
Disability insurance endorsed by the State Bar of Texas Insurance Trust as a benefit of your membership. 0257930-00001-00 LONG TERM DISABILITY PLAN Long Term Disability Insurance Helps Protect You and
More informationACCIDENT CLAIM FORM. 5. Was patient hospitalized? Yes No NAME OF HOSPITAL CITY STATE
ACCIDENT CLAIM FORM INSTRUCTIONS: 1. Please make sure all questions are complete on this form. 2. If we request an authorization form from you, please complete, sign and date the authorization form we
More informationA 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 informationapplication for survivorship joint life insurance Part 1
AMERITAS LIFE INSURANCE CORP. (ALIC) LINCOLN, NEBRASKA 68501 INFORMATION REGARDING INSURED A 1.A. Name: Last First Middle application for survivorship joint life insurance Part 1 Male Female INFORMATION
More informationGroup 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 informationTHE HARTFORD 1 GUIDE TO. Term Life Insurance
THE HARTFORD 1 GUIDE TO Term Life Insurance 44 percent of U.S. households had individual life insurance as of 2010 a 50-year low. In 1992, 55 percent owned it. In 1960, 72 percent of Americans owned individual
More informationE-Z TERM APPLICATION Foresters Life Insurance Company (the Insurer )
E-Z TERM APPLICATION Foresters Life Insurance Company (the Insurer ) 1. PROPOSED LIFE INSURED 2. OWNER (If not the Proposed Life Insured) Name: Male Female Last First Middle Date of Birth Age (last) Year
More informationDate of Change: If marriage, divorce or birth of a child, please provide copy of document. Social Security Number
Reliance Standard Life Insurance Company Enrollment and Statement of Health Name of Employer Presbyterian College Policy # and Class # Policy # and Class # Policy # and Class # Policy # and Class # Bill
More informationEvidence/Proof of Insurability for Group Life Insurance
Evidence/Proof of Insurability for Group Life Insurance This form is for residents of: AR, CO, FL, GA, IN, IA, KS, MD, ME, MO, NY, OR, PA, SD, TX and WI. Evidence/Proof of insurability is required in any
More informationSimple, Affordable & SAFE!
The Insurance & Benefits Trust of PORAC Simple, Affordable & SAFE! Group Term Life Insurance Application (5-Year Age Banded Rates, 10 & 20-Year Group Level Term Rates) P-01_06/12 ReliaStar Life Insurance
More informationFAMILY LIFE INSURANCE COMPANY Administrative Office: 10777 Northwest Freeway, Houston, Texas 77092 PART I, Application for Life Insurance
FAMILY LIFE INSURANCE COMPANY Administrative Office: 10777 Northwest Freeway, Houston, Texas 77092 PART I, Application for Life Insurance 1. Proposed Insured/Applicant (First, Middle, Last) up to 21 characters
More informationBoston Mutual Life Insurance Company. Group Disability Claim Filing Instructions
WISCONSIN Boston Mutual Life Insurance Company Group Disability Claim Filing Instructions IMPORTANT: All portions of this claim form must be completed after disability begins to avoid undue delay in processing
More informationApplication for Accidental Death Insurance
The Independent Order of Foresters ( Foresters ) - A Fraternal Benefit Society. U.S. Mailing Address: P.O. Box 179, Buffalo, NY 14201-0179 T. 800 828 1540 foresters.com Application for Accidental Death
More informationA 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 informationEVIDENCE OF INSURABILITY COVERAGE DETAIL
EVIDENCE OF INSURABILITY COVERAGE DETAIL This application consists of two parts: The Evidence of Insurability Coverage Detail form and Medical & Lifestyle Questionnaire. INSTRUCTIONS Plan Administrator:
More informationACCIDENT INSURANCE CLAIM
ACCIDENT INSURANCE CLAIM ReliaStar Life Insurance Company A member of the ING family of companies Administered by: Key Benefit Administrators, Inc., P.O. Box 1238 Fort Mill, SC 29716 Phone: 866-225-8704,
More informationPRELIMINARY LIFE INSURANCE APPRAISAL REQUEST
PRELIMINARY LIFE INSURANCE APPRAISAL REQUEST INSURED INFORMATION (If more than one insured, please duplicate this page and complete for each insured.) Name SSN Current Address Date of Birth Day Telephone
More informationToll Free: 1-800-276-7619, Ext. 4264 AssureLINK Address: http://assurelink.assurity.com
Toll Free: 1-800-276-7619, Ext. 4264 AssureLINK Address: http://assurelink.assurity.com Ohio Application for Simplified Critical Illness Insurance This application includes all forms needed to apply for
More informationTips for Submitting a Complete and Compliant Replacement
Tips for Submitting a Complete and Compliant Replacement If the application being submitted includes existing coverage, the following tips will assist in completing the replacement form and application.
More informationArizona Life Settlement Qualification Form
PERSONAL INFORMATION Arizona Life Settlement Qualification Form First Insured Name: SS # Current Address: City: State: Zip: Date of Birth: Driver s License Number: State: Expiration: Second Insured Name:
More informationFINAL EXPENSE WHOLE LIFE
FINAL EXPENSE WHOLE LIFE Regular Mail: United Farm Family Life Insurance Company P.O. Box 7192 Indianapolis, IN 46207-7192 FAX Number: 317-692-7711 Telephone: 800-428-3001 # pages including cover Fax only
More informationPolicy Evaluation and Application Form
1507 Park Center Drive, Unit 1B Orlando, FL 32835 888-335-4769 Fax: 321-400-1084 www.assetlifesettlements.com Personal Data Policy Evaluation and Application Form First Insured Name: SS #: Current Address:
More informationSenior Tribute Life Insurance NEW YORK
Senior Tribute Life Insurance from American Progressive Life & Health Insurance Company of New York, a member of the Universal American family of companies. NEW YORK PR-STL-APPK 09 NY Rev. 1/2011 Senior
More informationLeaders Life Insurance Accident Claim Filing Instructions
Leaders Life Insurance Accident Claim Filing Instructions Page One Filing Instructions: Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which
More information