GROUP TERM LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PORTABILITY APPLICATION

Transcription

1 Continental American Insurance Company (the Company ) 300 Southborough Drive, Suite 200, South Portland, ME Telephone: ; Fax: GROUP TERM LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PORTABILITY APPLICATION INSTRUCTIONS PLEASE READ CAREFULLY Portability of Insurance You may be eligible to buy portable Group Term Life Insurance if your employment with your employer terminates. If your employer s Group Term Life Insurance Policy includes Dependent Life or Accidental Death and Dismemberment (), you may also be eligible to buy those portable insurance coverages. To be eligible, you must meet the following requirements: 1. You must have been insured under your employer s Group Term Life Insurance Policy on the date your employment terminates. 2. You must be able to perform with reasonable continuity the material duties of at least one gainful occupation for which you are reasonably fitted by education, training and experience on the date your employment terminates. 3. You must be under age 65 on the date your employment terminates. The minimum and maximum amounts of insurance eligible for Portability of Insurance are shown in your employer s Group Term Life Insurance Policy. The amounts of insurance you purchase under the Portability of Insurance provision cannot be increased from current coverage. If you do not port Life insurance for yourself, you may not port any other insurance coverages, such as Dependent Life and. Options Refer to the Life Insurance Conversion provision in your Employer s Group Term Life Insurance Policy for information regarding eligibility to convert to an individual Life insurance policy. You may also wish to contact an independent insurance agent to discuss other alternatives. How to Apply You must apply in writing and pay the first two months of premium to us within 31 days after the date your employment terminates. You are responsible for making sure the attached form is completed and returned to our office. Processing will begin when this form, completed by you, is received by us. If you have questions, please contact our office at the telephone number shown above. If your application is approved, you will receive a notification of approval. Your current Group Term Life Insurance certificate provides a complete description of coverage. The certificate will contain provisions that will be different from your employer s Group Term Life Insurance Policy. NOTE: Your portability coverage will be reduced or terminated according to the terms of the Group Term Life Insurance Policy. Group Term Life Portability Insurance ends automatically on the earliest of: 1. The date it would otherwise end under the Group Term Life Insurance Policy. 2. The date the last period ends for which we received the required payment. 3. The date you become a full-time member of the armed forces of any country. 4. For any Life Insurance: The lesser of 5 years or the date you reach age For any Insurance: The lesser of 5 years or the date you reach age 70; or the date your Life Insurance ends. 6. For any Spouse Insurance, the date of your divorce or legal separation. 7. For any Spouse or Child Insurance, the lesser of 5 years or the date you reach age 70. Your check will be deposited into a conditional receipts account while your application is pending. This does not constitute approval of your application or waiver of the policy s eligibility requirements. If we determine that you are not eligible for coverage, all funds will be returned to you. Beneficiary Designation Beneficiary designations that you made under your employer s Group Term Life Insurance Policy will not apply to Group Term Life Portability Insurance. If you wish to designate a beneficiary for Group Term Life Portability Insurance, please complete the Beneficiary section on page 4. If you do not designate a beneficiary, payment of any benefit will be made in accordance with the Benefit Payment and Beneficiary provisions of your Employer s Group Term Life Insurance Policy. PORT APP 5/70 (10/17) Page 1

2 APPLICATION FOR GROUP TERM LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PORTABILITY Please print. COMPLETE ENTIRE FORM. To be completed by the Employer EMPLOYER INFORMATION Company Name Insured on disability/sick leave when terminated? Reason for Loss of Coverage Policyholder signature Policyholder telephone Group Policy Number Date Employment Terminated Current Annual Earnings Date Policyholder To be completed by the Applicant MEMBER INFORMATION Name (Last, First, Middle) Birthdate (MM/DD/YY) Gender M F Social Security Number Home Address Number/Street City State Zip Home Phone Number Name of Employer Group Number ( ) SPOUSE INFORMATION (if applicable) Spouse Name (Last, First, Middle) Spouse Birthdate (MM/DD/YY) ELIGIBILITY Are you able to perform with reasonable continuity the material duties of at least one gainful occupation for which you are reasonably fitted by education, training and experience? Yes No Are you under the age of 65 on the date your employment terminates? Yes No AMOUNT OF INSURANCE COVERAGE REQUESTED Group Term Life and, if applicable, Dependents Group Term Life Insurance Insurance (if applicable) Member $ $ Spouse $ $ Children $ $ BILLING: If approved, you will be billed monthly at your home address. Premium must be received by the due date. ACH is available upon request. If requested, we will send you an ACH form to complete. You must complete the form and pay the first two months of payments within 31 days after the date your employment terminates. PORT APP 5/70 (10/17) Page 2

3 PREMIUM COMPUTATION Use the tables below to calculate your monthly premium rate at the time your coverage is issued. Premium rates are subject to increase with advancing age. Premium rates are not guaranteed and may be changed by the Company with advance written notice. Approved applicants will be billed monthly. Checks are to be made payable to Continental American Insurance Company. Premium must be received by the due date. Monthly Premium Rates per $1,000 of Insurance Age Employee Life Employee Life & Spouse Life Spouse Life & Child Life Child Life & Group Term Life and, if applicable, and Dependent Life Insurance 1. Age of Employee 2. Monthly Rate for age from above table 3. Amount of Insurance 4. Divide Line 3 by 1, Multiply Line 4 by Line 2 Employee Spouse Child Total Premium Due Add all items in Line 5 to arrive at Total Monthly Premium Due $ PORT APP 5/70 (10/17) Page 3

4 BENEFICIARY DESIGNATION This beneficiary designation applies to all of your Group Term Life Portability Insurance and Accidental Death and Dismemberment Insurance, if any. If you name two or more beneficiaries in a class (Primary or Secondary): (1) Two or more surviving beneficiaries of the same class will share equally, unless you provide for unequal shares. (2) If you provide for unequal shares in a class, and two or more beneficiaries in that class survive, we will pay each surviving beneficiary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise due to any deceased beneficiary(ies) to the surviving beneficiaries pro rata based on the relationship that the designated percentage or fractional share of each surviving beneficiary bears to the total shares of all surviving beneficiaries. (3) If only one beneficiary in a class survives, we will pay the total death benefits to that beneficiary. Note: We will only pay a secondary beneficiary if the Primary beneficiaries do not survive you. If no beneficiary (Primary or Secondary) survives you, payment will be made as provided in the Portability provision of the Group Term Life Insurance Policy. Insurance on your Spouse or other Dependents, if any, is payable to you, if living, or as provided under the terms of the Portability provisions of the Group Term Life Insurance Policy. Note: If death occurs and a minor is the beneficiary, it may be necessary to have a guardian or a legal representative appointed before any death benefit can be paid. Class: Primary Class: Secondary PORT APP 5/70 (10/17) Page 4

5 AGREEMENT I hereby apply for Group Term Life Portability Insurance and Accidental Death and Dismemberment Insurance, if applicable. I agree that no coverage will take effect until it is approved in writing by Continental American Insurance Company. I understand that if my application is not accepted, any premium advanced by me will be refunded. I understand that if I do not designate a beneficiary in the Beneficiary section on the preceding page, payment of any benefit will be made in accordance with the Benefit Payment and Beneficiary provisions of the Portability provision in the Group Term Life Insurance Policy. I hereby represent that all statements contained herein are complete and true to the best of my knowledge and belief, and that I meet all eligibility requirements. I have read and understand the information herein, including the applicable Fraud Notice below. I understand that answers that are not true or complete may cause benefits to be denied or may invalidate coverage. FRAUD NOTICES The following fraud notice applies: Any person who knowingly presents a false statement in a statement of insurability for insurance may be guilty of a criminal offense and subject to penalties under state law. FOR RESIDENTS OF THE DISTRICT OF COLUMBIA. Any person who knowingly and with intent to injure, defraud or deceive an insurance company, or other person, files a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines may be imposed. FOR RESIDENTS OF FLORIDA. Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree. FOR RESIDENTS OF NEW YORK. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Dated at: On: / / City State Month Day Year Signature of Employee Printed Name of Employee A REMINDER! Don t forget to: Complete the beneficiary information Sign and date this form Include the first two months of premium Send this form and your premium within 31 days after the date your employment terminates to: Continental American Insurance Company 300 Southborough Drive, Suite 200 South Portland, ME Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, group coverage is underwritten by Continental American Life Insurance Company. For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. PORT APP 5/70 (10/17) Page 5