Application/Change Form For Individual Dental Insurance

Transcription

1 U?Te Empl And its Affiliates and Subsidiaries P.O. Box , Sacramento, CA Application/Change Form For Individual Dental Insurance AGENT/AGENCY INFORMATION Please print clearly and mark carefully. Agent Name: Agency Contact: Agent Number: Phone Number: Agency Name: Fax Number: Agency Number: TYPE OF ACTIVITY (Please check appropriate box) Initial Application - If not a new applicant, check appropriate box and list affected policy number. Re-Application Add Spouse/Dependent Information Change Existing Policy # Loss Of Other Coverage: I and/or my dependents were previously covered under another insurance plan. Loss of coverage date: - - Primary Proposed Policyowner: First, MI, Last Name: Address/City/State/Zip: Gender: : - - Phone: ( ) - Address: DEPENDENTS TO BE INSURED Spouse [Domestic Partner] (First, MI, Last Name) Gender Child/Dependent 1: Add Drop Gender Child/Dependent 2: Add Drop Gender Child/Dependent 3: Add Drop Gender Child/Dependent 4: Add Drop Gender

2 Are any proposed Insureds covered by, or has application/enrollment been made for any type of dental insurance? If "Yes", complete the section below. Insurance Company Name Policy Number Effective Date (MM/DD/YYYY) Is this coverage being replaced by proposed coverage? DENTAL COVERAGE ELECTION Check only one box. Individual Only Individual & Spouse Individual & Dependent/Child(ren) Individual, Spouse & Dependent/Child(ren) AUTHORIZATION This application form, recorded Authorizations and any amendments shall be the basis for the policy. The insurance, if approved by Guardian Life Insurance Company of America, will be in force only when issued by Guardian Life Insurance Company of America. The premium must be paid when due. A change in my eligibility or the proposed dependent(s) after the completion of the application form and before the delivery of the contract may affect my eligibility for insurance with the company. I understand and agree that any information I provide through this application form process may be shared with persons necessary to facilitate issuing coverage, including but not limited to my agent or broker. I understand that I have a right to receive a copy of this authorization. I understand that this authorization is required in order to enable Guardian Life Insurance Company of America to make eligibility or application determinations relating to me and/or my dependent(s). If I refuse to sign or revoke this authorization, Guardian Life Insurance Company of America may refuse to consider this application for insurance. I understand that I may revoke this authorization at any time by notifying Guardian Life Insurance Company of America in writing of my desire to revoke. Such revocation must be sent by certified mail to the following address: P.O. Box , Sacramento, CA Such revocation will not be valid if Guardian Life Insurance Company of America has taken action in reliance on the authorization. Unless an earlier date is required by law, this authorization expires upon the earliest of the following events: 30 days after denial of this application, or if insured, 30 days after no longer being insured by Guardian Life Insurance Company of America. But in no event will this authorization be in effect for longer than 24 months from the date signed. I agree that a photocopy of this authorization shall be valid for two years from the date signed. I acknowledge receiving the notification regarding the Abbreviated Notice of Insurance Information Practices and the Outline of Coverage for dental Insurance, if required. I acknowledge that I have read the completed application form. I attest that all statements and answers on this application form are complete, true and correct. I understand and acknowledge that any fraudulent statement or material misrepresentation or omission on the application form, recorded Authorizations and/or any amendments may result in claim denial or contract rescission, subject to the Incontestability provision of the policy. I acknowledge and consent to receiving electronic copies of applicable insurance related document, in lieu of paper copies, to the extent permitted by applicable law. I may change this election only by providing 30 days prior written notice. THIS POLICY PROVIDES DENTAL BENEFITS ONLY. REVIEW YOUR POLICY CAREFULLY. SIGNATURE OF PROPOSED POLICYOWNER X DATE

3 AGENT AUTHORIZATION Attention: (Agent) I have reviewed this application form to ensure that all required items have been completed. I certify that: I personally saw the applicant. The applicant was asked each required question and the answer is truly and accurately recorded on the application form in the respective response area. The answers are true to the best of my knowledge. The application was completed by the proposed policyowner or representative and the answers are true to the best of my knowledge. Licensed Resident Agent s Signature Print Agent s Name Initial here if You witnessed the signing of this form by the proposed policyowner. COLLECTION OF PAYMENT Select your payment method (check one): Monthly Check/Money Order Monthly Bank Draft For Check Payments: Checks are payable to Guardian Life Insurance Company of America. Banking Information: Please charge my (check one): Checking Account (include a voided check) Savings Account (include a voided deposit slip) I hereby authorize Guardian Life Insurance Company of America to debit the designated prepayment fee each month from the bank account indicated above. I understand that the amount of my monthly prepayment fee will be deducted from my account and that there will be a 2 [ $25 ] service charge for any returned drafts. THIS POLICY PROVIDES DENTAL BENEFITS ONLY. REVIEW YOUR POLICY CAREFULLY. AUTHORIZATION OF PROPOSED POLICYOWNER X DATE

4 IMPORTANT NOTICES - LEAVE WITH CUSTOMER ABBREVIATED NOTICE OF INSURANCE INFORMATION PRACTICES To issue an insurance policy, We need to obtain information about You and any other person proposed for insurance. Some of that information will be received from You, and some will be generated from other sources. That information and any subsequent information collected by Us may in certain circumstances be disclosed to third parties without Your specific authorization. You have the right of access and correction with respect to the information collected about You except information which relates to a claim or civil or criminal proceeding. If You wish to have a more detailed explanation of Our information practices, please contact Guardian Life Insurance Company of America, Underwriting Department, P.O. Box , Sacramento, CA FRAUD NOTICE It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. The state in which the policyowner resides may have a specific state fraud warning. Please refer to the attached Fraud Warning Statements page. PRIVACY We do not disclose any non-public personal information about Our customers or former customers to anyone, except as permitted by law. We collect non-public information about You from the following sources: (1) information We receive from You on application forms or other information related thereto or as part of policy administration, and (2) information about Your transactions with Our affiliates, others or Us. We restrict access to non-public personal information about You to those who need to know that information to provide products or services to You. We maintain physical, electronic and procedural safeguards that comply with federal standards to guard Your non-public personal information. We may disclose non-public personal information about You to nonaffiliated third parties as permitted by law. Fraud Warning Statements The laws of several states require the following statements to appear on the enrollment form: Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Connecticut, Iowa, Nebraska, and Oregon: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of a fraudulent insurance act, which may be a crime, and may also be subject to civil penalties. Delaware, Indiana and Oklahoma: WARNING: Any person who knowingly, and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

5 District of Columbia: 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. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kansas: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of insurance fraud as determined by a court of law. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim 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. Louisiana and Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to fines and confinements in state prison. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment or a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties or denial of insurance benefits. Maine, Tennessee, and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefit. Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. 638:20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Ohio: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 subjects such person to criminal and civil penalties. Rhode Island: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Vermont: 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. Virginia: Any person, who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.