Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, been positively diagnosed or treated for: chest
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1 To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR NSBA GROUP INSURANCE PROGRAM P.O. Box Des Moines, IA QUESTIONS? Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Nebraska State Bar Association G MO Group Policy No. G-201,230 4/17 AG /21862/ 1018/
2 Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, been positively diagnosed or treated for: chest pain; disease or disorder of the heart, liver, kidneys, blood or lungs; high blood pressure; stroke or other neurological disorder; mental/nervous disorder; drug or alcohol abuse; diabetes; cancer or tumor; Acquire Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or tested positive for an immune disorder? G Yes G No G Yes G No 2. Has the applicant/member or spouse, if applying, during the past 5 years, consulted any physician or other practitioner or been confined or treated in any hospital or similar institution, for any reason other than those stated above? G Yes G No G Yes G No 3. Has the applicant/member or spouse, if applying, used tobacco or nicotine in any form during the past 12 months? G Yes G No G Yes G No 4. Is the applicant/member or spouse, if applying, now taking prescription medication or receiving medical attention? G Yes G No G Yes G No For "Yes" answers to questions 1-4 above, please provide details in the space provided below. If more space is needed, use a separate sheet of paper, signed and dated. If additional information is attached, check "Yes" in the box at the right G Yes G No * * G MO Group Policy No. G-201,230 4/17 AG
3 AUTHORIZATION AND DECLARATION OF EACH PERSON GIVING A STATEMENT OF INSURABILITY I hereby authorize any licensed physician, medical practitioner, pharmacy, pharmacy benefit manager and other sources, hospital, clinic, or other medical or medically related facility, insurance company, the MIB, Inc., or other organization, institution or person that has any records or knowledge of me or my health, to give to the Company or its reinsurers any such information. Such information will pertain to my employment, or other insurance coverage and medical care, advice, treatment or supplies for any physical or mental condition. This includes information obtained in connection with the preparation or procurement of an investigative consumer report as defined under the Fair Credit Reporting Act(s). To facilitate the rapid submission of such information, I authorize all said sources, except the MIB, to give such records or knowledge to any agency employed by the Company to collect and transmit such information. I understand that this information will be used by the Company solely to determine eligibility for insurance. I understand that I may revoke this authorization at anytime by giving written notice to the Company. I agree that such revocation will not affect any action, that any source has taken in reliance upon this authorization. I understand this authorization will be valid for 24 months from the effective date of coverage, if not revoked earlier. I know that I should retain a copy of this authorization for my records. I agree that a photocopy of this authorization is as valid as the original. To the best of my knowledge and belief, all statements made above are true and complete. I understand that my application for group insurance will be accepted or declined on the basis of these statements. Insurance will take effect only if a certificate is issued based on this application and the first premium is paid in full (a) during the lifetime of all proposed insureds; and (b) while there is no change in the insurability or health of such person from that stated in the application. *Wherever the term spouse appears will read as Domestic Partner throughout the application. **Dependent Child must be unmarried, up to 23 years of age if a full-time student (subject to state variations). All dependents must be dependent in accordance with IRS guidelines. Important Notice: 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 may be a crime. Date Date Member/Applicant's Signature Spouse/Domestic Partner's Signature G MO 3 Group Policy No. G-201,230 4/17 AG
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5 Group Policy No. G-201,230 4/17 AG
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11 FOR NSBA MEMBERS AND THEIR FAMILIES
12 Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA Administered by: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA Questions? AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC MN Insurance License # OK Insurance License # TX Insurance License # Underwritten By: The United States Life Insurance Company in the City of New York 3600 Route 66 P.O. Box 1580 Neptune, NJ Policies issued by The United States Life Insurance Company in the City of New York (US Life). Issuing company US Life is responsible for financial obligations of insurance products and is a member of American International Group, Inc. (AIG). Products may not be available in all states and product features may vary by state. Policy #G-201,230 Form #G This brochure is a brief description of benefits only and is subject to the terms, conditions, exclusions and limitations of the group policy. The most prominent independent ratings agencies continue to recognize The United States Life Insurance Company in the City of New York in terms of insurer financial strength. For current insurer financial strength ratings, please consult the Web site at If applicable, an additional $2 billing fee will be included on your billing notice payable to the administrator. To save the fee, select Electronic Funds Transfer (EFT) as a safe and secure payment option. Copyright 2017 Mercer LLC. All rights reserved. * *
Please answer these brief questions. Member Spouse 1. To the best of the applicant's/member's knowledge and belief, has the applicant/member or spouse
ADMINISTRATOR AACN GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-503-9230 customerservice.service@mercer.com Underwritten by The United States Life Insurance Company
Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated
To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR SPJ GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-503-9230 customerservice.service@mercer.com
Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever been diagnosed with, or been treated for:
To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR SPJ GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-503-9230 customerservice.service@mercer.com
Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated
To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR NCRA GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-503-9230 customerservice.service@mercer.com
Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated
To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR SPJ GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-503-9230 customerservice.service@mercer.com
Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated
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