GREEK CATHOLIC UNION OF THE USA A FRATERNAL BENEFIT SOCIETY

Transcription

1 GREEK CATHOLIC UNION OF THE USA A FRATERNAL BENEFIT SOCIETY Application, Life Insurance Please Print, Use Dark Ink 1. Proposed Insured, Name: Date of Birth: Place of Birth: Height: Weight: Mo-day-Yr City State Home Address: Number Street City State - ZIP [ ] Male [ ] Female Occupation: Employer: Soc. Sec. No: Tel. No.: Amount of life insurance in force: Is the Proposed Insured a member of the Greek Catholic Union of the USA? [ ] Yes. [ ] No. If not, apply for membership. 2. Plan: Face Amount: Riders: Requested Effective Date: Premium Mode: Automatic Premium Loan, if available? [ ] Yes. [ ] No. Dividend Option: Amount paid with this application: Will the insurance applied for replace or change any existing insurance or annuity? [ ] No. [ ] Yes; show name of insurer(s) and contract numbers: 3. Beneficiary. (Give: Full Name(s), Social Security Number, Relationship to Insured and Share of Proceeds) Primary: Contingent: 4. Owner. [ ] Proposed Insured, must be age 16 or older. [ ] Applicant. [ ] Other; provide full name, address, and relationship to Proposed Insured: 5. In the past 3 years has the Proposed Insured: Yes No a. used tobacco in any form... [ ] [ ] b. engaged in any hazardous sport or activity, such as skin - or sky-diving, or car, motorcycle or boat racing; or do you intend to do so?... [ ] [ ] c. flown as a pilot or crew member of any type of aircraft; or, intend to do so?... [ ] [ ] d. had his or her license to drive suspended or revoked?... [ ] [ ] Details, any Yes answer: Form AL

2 6. In the past 5 years, has the Proposed Insured received: care or treatment from a licensed medical practitioner; or been confined in a medical care facility, for: Yes No a. asthma; emphysema; or, other lung or respiratory disease or disorder?... [ ] [ ] b. epilepsy; loss of consciousness; or mental or nervous system disease or disorder?... [ ] [ ] c. diabetes; thyroid disease or disorder; or, any disease or disorder of the glands?... [ ] [ ] d. kidney disease or disorder; blood, sugar or pus in the urine; venereal disease; or, other genito-urinary disease or disorder?... [ ] [ ] e. high or low blood pressure; anemia; chest pain; rheumatic fever; heart disease or disorder; or, other circulatory disease or disorder... [ ] [ ] f. stomach ulcer; colitis, or, other disease or disorder of the stomach, rectum, gall bladder, liver or intestines?... [ ] [ ] g. cancer; tumor; malignancy; or, abnormal growth of any kind?... [ ] [ ] h. eye, ear, nose or throat disease or disorder?... [ ] [ ] i. use of alcohol or use of drugs other than prescription drugs?... [ ] [ ] j. any disease or disorder not listed above; or, any deformity... [ ] [ ] k. any surgical operation, scheduled or completed?... [ ] [ ] 7. In the past 5 years, has the Proposed Insured: Yes No a. been diagnosed by a licensed medical practitioner as having AIDS (Acquired Immune Deficiency Syndrome)?... [ ] [ ] b. been tested, using a FDA-licensed blood test, for the HTLV-III antibody with positive test results?... [ ] [ ] When this application is written in the State of: (1) Minnesota, HTLV-III testing need not be disclosed when such test is performed: on an offender under 611A.19 Minnesota Statutes; or, on a crime victim who was exposed to or had contact with an offender s bodily fluids during the commission of a crime that was reported to law enforcement officials. (2) Wisconsin, HTLV-III testing at an anonymous counseling and testing site need not be disclosed. 8. Details, any Yes answer question 6 or 7. Identify question and include: diagnosis, dates, and names and addresses of all attending medical practitioners and medical care facilities. 9. Does the Proposed Insured have a family history of: heart disease, diabetes, cancer, or mental illness? [ ] No. [ ] Yes; details: 10. Name and address of Proposed Insured s family doctor; (If none so state.) Form AL

3 EACH PERSON signing this application and any continuation or supplement thereto: (1) REPRESENTS that, to the best of such person s knowledge and belief, all statements and answers therein are complete, true and accurately recorded; (2) AGREES that, such forms shall be the basis for and a part of any contract of life insurance issued; and (3) UNDERSTANDS that, no agent or person other than an executive officer of the Society may; (a) change, modify or waive any of the printed statements herein; or (b) waive any of the Society s rights or requirements. Except as may be provided in a receipt bearing the same date as this application, no insurance shall take effect unless and until: (1) this application is approved by the Society at its Home Office; (2) a contract is issued, delivered to and accepted by its owner; and (3) the full first premium for the contract is paid. All must occur while the health and other factors affecting the insurability of the Proposed Insured remain as described in this application. AUTHORIZATION. Any; medical practitioner; medical care facility; insurer or reinsurer; the Medical Information Bureau (MIB); consumer reporting agency; employer; institution; or, person, that has any information (*) regarding me is hereby authorized to provide such information to: Greek Catholic Union of the USA or its reinsurer; or, except for the MIB, to its legal representative. I further authorize Greek Catholic Union of the USA to obtain an investigative consumer report. (*) When this application is written in the State of: (1) Minnesota disclosure is not required of any test to determine the presence of the HTLV-III antibody when such test is performed on the perpetrator or victim of a crime that was reported to law enforcement officials; or (2) Wisconsin disclosure of HTLV-III antibody test results is not required when such test is completed at an anonymous counseling and testing site. The information obtained will be used to determine eligibility for life insurance and benefits. The information will be treated as confidential and will not be disclosed except: to the Greek Catholic Union of the USA s reinsurer; to the MIB; to persons or organizations performing business or legal services in connection with this application or a claim for benefits; or, as may be legally required. This Authorization shall be valid for a period of 24 months from the date shown below. A photocopy shall be valid as the original. I understand that, on request, I may receive a copy of the above Authorization. I acknowledge receipt of Notice Parts 1 and 2. Signed at: this day of, 20 Proposed Insured Member Applicant or Adult Applicant or Owner other than Proposed Insured (Complete for applications written in Florida only: Agent s name, print: Witness (licensed agent where required) Agent s Florida Identification Number: ) Ohio Residents: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against the insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Form AL

4 AGENT S REPORT (Not a Part of the Application) 1. To the best of your knowledge and belief, will the insurance applied for replace or change any existing insurance or annuity? [ ] No. [ ] Yes; comply with any replacement regulations. 2. How long have you known the Proposed Insured? State any relationship: 3. Is the Proposed Insured: [ ] Byzantine Catholic. [ ] Roman Catholic. 4. Lodge No.: ; located at: 5. Has the name of the Proposed Insured changed in the past 5 years? [ ] No. [ ] Yes: former name Date of change; reason for change: 6. Are you aware of any information, not disclosed in the application, which might have a bearing on the issue of the insurance applied for? [ ] No. [ ] Yes; details: 7. If the Proposed Insured is under age 16, complete the following: Applicant s relationship to Proposed Insured: Insurance in force: Applicant: Siblings, if any: Agent s signature: Code No s: Agent: Manager: Form AL

5 GREEK CATHOLIC UNION OF THE USA (GCU) Conditional Receipt 5400 Tuscarawas Road, Beaver, PA THIS RECEIPT DOES NOT PROVIDE INSURANCE UNTIL ITS CONDITIONS ARE MET. Received from: an application on the life of: the sum of: in connection with Date: Agent: Please contact GCU if you do not, within 60 days from the date of this receipt, receive: the contract applied for; or, a return of the amount paid. Please include: the name of the agent; and, the date and amount paid. Do not pay in cash. All remittances must be payable to GCU. Do not make payable to Agent or leave the payee blank. CONSUMER REPORT Notice Part 1 This notice is to inform you that GCU may obtain an investigative consumer report, as you have authorized. If obtained, the report will include information obtained through personal interviews with third parties, such as: financial sources; business associates; family members; friends; neighbors; or, others with whom you are acquainted. The report may include information as to your; character; general reputation; personal characteristics; and, mode of living. Within a reasonable period of time, you may, in writing, request additional, detailed, information regarding the nature and scope of any such report. The insurance applied for will be effective: (1) on the later of: (a) the date of the application; (b) the last date of any initially required medical test(s) or examination(s); or (c) the effective date requested in the application; and (2) provided, the following conditions are met, exactly; (a) the Proposed Insured is found to be a standard risk for the amount and plan applied for in accordance with GCU's underwriting rules then in effect; (b) the amount paid is sufficient to pay the first mode premium for the amount and plan applied for including any riders; and (c) the payment received is good and collectible. The maximum amount of insurance which may become effective under this Conditional Receipt is determined by the age of the Proposed Insured on the application date and may not exceed: (1) $100,000 at age 64 or less; or (2) $50,000 at age 65 more. Such maximum amount shall include: (1) any accidental death benefits applied for; and (2) any other pending application for the Proposed Insured. MEDICAL INFORMATION BUREAU (MIB) Notice Part 2 Information regarding your insurability will be treated as confidential. GCU or its reinsurer may, however, make a brief report thereon to the MIB, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member for life or health insurance coverage, or if a claim for benefits is submitted to such member, the MIB will, upon request, supply such member with the information it may have in its file. (Medical information will be disclosed only to your attending physician.) If you question the accuracy of the MIB file information, you may contact the MIB and seek a correction in accordance with procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB s information office is: Box 105, Essex Station, Boston Massachusetts 02112; telephone: (617) GCU or its reinsurer may also release file information to other insurers to whom; you may apply for life or health insurance; or, a claim may be submitted. Form AL

6 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

7 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