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

Transcription

1 AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA Remarks: ENROLLMENT FORM c New Certificate c Change/Increase Certificate # This box for AHL Home Office use only GENERAL INFORMATION Employee s/payor s/owner s (Certificateholder) Name (Last, First, M.I.) Residence Address City c M c F Social Security Number State Zip Date of Birth Phone Number Employer/Association/Union Date Hired Occupation Plant Or Division Primary Beneficiary s Full Name and Address City State Zip Relationship Phone Number Date of Birth Contingent Beneficiary s Full Name and Address City Social Security Number State Zip Relationship Phone Number Last Name Date of Birth COMPLETE THIS SECTION FOR PERSONS TO BE INSURED First Name Relationship Sex Date of Birth Social Security Number Employee Spouse Social Security Number Tobacco Use* (Life or Critical Illness) ** ** *Has any adult (19 and older) person to be insured used tobacco in the last 12 months? (**If applying for Life or Critical Illness. For Critical Illness, tobacco rating applies to all covered persons if either the employee or the employee's spouse answers "Yes" to Tobacco Use.) Are you applying for coverage or changing existing coverage due to a qualifying event? Accident Disability (STD) Cancer/Specified Disease Hospital Indemnity Critical Illness Term Life Dental Universal Life If Yes, check the qualifying event: c Marriage c Spouse/Dependent Child Death c Newly Eligible c Divorce c Eligible/Ineligible Child c Termination c Birth/Adoption c Spouse New Job/Job Loss c Employee Death Date of Qualifying Event Current Certificate Number(s) Do you currently have any of the following Individual coverages with American Heritage Life Insurance Company (AHL)? Accident Cancer Critical Illness Disability Hospital Indemnity If you answered Yes to any of the coverages, please enter the Policy Number Do you wish to terminate this coverage? If Yes, please enter effective date of termination ABJ45807 Page 1 of 5

2 ENROLLMENT FORM /Billing Mode c Monthly c Semi-monthly c Bi-weekly c Weekly c Other Date of First Deduction Coverage Effective Date Account Number Employee ID Situs State Accident (GVAP6) On and Off the Job Accident Off the Job Accident Base SELECTION OF COVERAGE (Answer Yes or No and complete for each coverage selected) c Accident Treatment & Urgent Care c Dislocation/Fracture c Emergency Room Services c Outpatient Physician s c Benefit Enhancement c Accidental Death, Dismemberment and Functional Loss Accident (GVAP2) (Off the Job Accident) Base c Benefit Enhancement Option Fracture Option c Outpatient Physician s c Continuation During Strike or Layoff c Refund Upon Layoff (Not available on plans) Accident (GVAP1) Base (On and Off the Job Accident) c Benefit Enhancement Fracture Option Optional Disability s for Employee Employee Monthly Salary c Off the Job Accident c Off the Job Accident and Sickness c On and Off the Job Accident c On and Off the Job Accident and Sickness c Continuation During Strike or Layoff c Refund Upon Layoff (Not available on plans) Cancer/Specified Disease (GVCP3) Benefits Hospital Radiation / Chemotherapy Surgery Related Misc. c Cancer Initial Diagnosis Option c Cancer Progressive Benefit Option c Intensive Care Option 1 c Continuation During Strike or Layoff c Refund Upon Layoff (Not available on plans) c Wellness Option Cancer/Specified Disease (GVCP2) Benefits Plan Hospital Radiation / Chemotherapy Surgery Related Misc. ABJ45807 Page 2 of 5 1 c Cancer Initial Diagnosis Option c Intensive Care Option c Cancer Screening Option

3 ENROLLMENT FORM Critical Illness (GVCIP4) Basic Benefit Amount c 2nd Evaluation, Transportation & Lodging c Specified Chronic Illness SELECTION OF COVERAGE (Answer Yes or No and complete for each coverage selected) c Reoccurrence of c Cardiopulmonary Enhancement c Specified Chronic Illness or Injury c Cancer c Lifestyle Enhancement Supplemental Critical Illness c With HIV c Without HIV c Reoccurrence of Cancer c Skin Cancer Wellness c Fixed c Variable Critical Illness (GVCIP2) Basic Benefit Amount c Supplemental Critical Illness Option II c 2 nd Event Cancer c Wellness Option c 2 nd Evaluation Benefit c Cancer Critical Illness Option c Supplemental Critical Illness Option I (HIV) c 2 nd Event Initial c Continuation During Strike or Layoff c Refund Upon Layoff (Not available on plans) Critical Illness (GVCIP1) (My Lifeline) Basic Benefit Amount If covered, Basic Benefit Amount for spouse is 50 of employee benefit; other dependents are 25 of employee benefit. c Critical Illness Cancer Option c Recurrence Option c Wellness Option c 2 nd Evaluation Benefit Disability (Short-Term) (GVDIP) (My Lifeline) Elimination Period: Days Acc. Family Medical Leave & Doula Services / Benefit Amount Monthly Salary Increasing Benefit Period Days Sick. Monthly Benefit Refund Upon Layoff * On-the-Job Accident Disability Benefit Period: Months Survivor & Accident c c c c c c c *Not available on. A. Is this insurance to replace any existing disability coverage? If yes, provide the Company Name B. Is there any other disability insurance in force or applied for that will continue after the effective date of this coverage? If yes, complete the following: Company Name Year Issued Monthly Benefit Elimination Period Benefit Period ABJ45807 Page 3 of 5

4 Hospital Indemnity (GVSP1) Benefits Hospital Related Surgery / Inpatient Physician ENROLLMENT FORM SELECTION OF COVERAGE (Answer Yes or No and complete for each coverage selected) Outpatient c Diagnostic / Wellness c Prescription Related Option Drug Option c Disability 1 c Continuation During Strike or Layoff c Refund Upon Layoff (Not available on plans) c Life Heritage Choice Dental c Plan 1 c Plan 4 c Plan 2 c Plan 5 c Plan 3 c Employee +One Child Were you covered under your Employer s prior Dental Plan? If Yes, please enter the date coverage effective Abbreviations: GI - Guaranteed Issue Life c Universal Life (UL) c Term Life Face Amount cx GI Death Benefit Option c 1 c 2 (UL ONLY) Employee s Annual Salary Life s /Amt Replacement and Existing Insurance Section (Must Answer) 1a. Replacement. Proposed Insured. Is this insurance to replace or change any existing life coverage? If yes, indicate product being replaced or changed and complete replacement form provided by your producer, if required by your state. 1b. Producer. To your knowledge, is change or replacement involved? 2a. Existing Insurance. Proposed Insured. Is there any other (not listed in Question 1a.) life insurance in force or applied for on the proposed insured? If yes, list company name, policy number, year issued, type of coverage, and amount of benefit. 2b. Producer. To your knowledge, does the proposed insured have existing coverage in force? Illustration Regulation Certification 3a. Illustration Certification. Owner. By answering yes, I certify that I did not receive an illustration conforming to the coverage applied for, and I understand that an illustration conforming to the coverage issued will be provided upon delivery of the certificate. By answering no, I will complete the applicable illustration certification form provided, if required in my state. 3b. Producer. By answering yes, I certify that no illustration conforming to the coverage applied for was provided, but that an illustration conforming to the coverage issued will be provided upon delivery of the certificate. By answering no, I will complete the applicable illustration certification form provided, if required. Disability & Life Eligibility Question Is the employee actively at work now, for wage or profit, and has he/she worked at least 20 hours each week performing all duties of his/her regular occupation at his/her regular place of employment for at least the last 3 months except for minor illness or injury of 1 week or less, or normal pregnancy? EMPLOYEE ABJ45807 Page 4 of 5

5 ACCEPTANCE/AUTHORIZATION. I hereby request all coverage(s) checked yes above for which I am or may become eligible under the group coverages issued by AHL. I AUTHORIZE my employer to deduct from my salary or wages, if applicable, the necessary premium for the coverages requested. EFFECTIVE DATE: I understand that the effective date of my elected coverages will be the effective date recorded on my Certificate, not the date this Enrollment form is signed. WAIVER/DECLINATION: I understand that if I refuse any coverage for which I am eligible (by checking no above), satisfactory proof of insurability may be required, at my own expense, should I desire to apply for it at a later date. Any such application may be declined on the basis of such proof. Date Signed Employee s Signature Producer s Statement. I certify that to the best of my knowledge and belief the information on this form is complete, accurate and correctly recorded. Signature of Soliciting Producer Print Soliciting Producer Name To be completed by home office or producer, prior to issue: Producer Name Producer Number Servicing Producer: Soliciting Producer: National Producer Number (NPN) Percentage Credit ABJ45807 Page 5 of 5

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