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1 imfmoore_mda-ca-groupdisabilityincome Office of the Administrator P.O. BOX Des Moines, IA Dear, Thank you for inquiring about the Minnesota Dental Association Group Insurance Program. Enclosed you'll find the information you requested for the following plan: Group Disability Income Plan. Before you take a look at the information I've enclosed, let me mention some of the important benefits you receive with all our insurance plans. l These are "group" plans, negotiated especially for MDA Members. Rates, although not guaranteed, can only be changed on a group basis. l Each plan is backed by a 30-day Free Look. After you receive your Certificate of Insurance, you have a full 30 days to review your new coverage. If you decide that it's not exactly what you want and need, simply return it. Every dollar you've paid will be refunded, and your coverage will be invalidated, no questions asked provided of course, you have not submitted any claims. Please read the enclosed brochure for more information, including eligibility, renewability, costs, exclusions, limitations and terms of coverage on this plan. Once you determine the type and amount of personal insurance protection you need, simply complete and return the application in the postage-paid envelope provided for approval. If you have questions along the way, just pick up the phone and call us. Our toll-free number is: Whatever your personal situation, I hope you'll take a few minutes today to candidly assess your family's insurance needs and apply to bring your coverage up-to-date through this exclusive member program. Please return your application today! Yours truly, Terence B. Bernier Managing Director Marsh U.S. Consumer a Service of Seabury & Smith, Inc. # P.S. Each insurance plan is offered through a well respected, highly rated insurance company, and every plan carries a 30-day Free Look! Marsh U.S. Consumer a Service of Seabury & Smith, Inc. P.O. BOX l Des Moines, IA l mda@marshpm.com l œseabury & Smith, Inc. March 2011 AGP
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3 For Members of the Minnesota Dental Association DISABILITY INSURANCE APPLICATION HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut TO APPLY: 1. Complete and sign the application 2. Send no money with your application. You will be billed upon approval. 3. Use the postage paid envelope provided to return to: MDA GROUP INSURANCE PROGRAM P.O. Box Des Moines, IA Minnesota Dental Association Annual Salary: $ The Hartford is Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Form PA-9357 (HLA) (CA) IDI648CAE-AGP5541E
4 Spouse/Domestic Partner's Name: (First, Middle Initial, Last), if applying Spouse/Domestic Partner's Occupation: Annual Salary: $ Section 4 COVERAGE REQUESTED: Member Coverage: GNew Coverage: Monthly Benefit Amount: $ GChange in Coverage: Increase my Monthly Benefit Amount to: $ GChange in Waiting Period: Waiting Period: G90 days G180 days Spouse/Domestic Partner Coverage: GNew Coverage: Monthly Benefit Amount: $ GChange in Coverage: Increase my Monthly Benefit Amount to: $ GChange in Waiting Period: Waiting Period: G90 days G180 days Has anyone proposed for coverage been actively engaged in the full-time duties of his or her occupation (at least 25 hours per week) immediately before the date of this application? You: GYes GNo Spouse/Domestic Partner: GYes GNo Is the Monthly Benefit Amount herein applied for equal to or less than 60% of your Pre-Disability Earnings minus any Other Income Benefits? You: GYes GNo Spouse/Domestic Partner: GYes GNo The Hartford is Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Form PA-9357 (HLA) (CA) IDI648CAE-AGP5541E 2 * *
5 Member Spouse/ Domestic Partner Section 8 AUTHORIZATION I hereby certify that I have read or have had read to me all statements and answers in this application, and in any other application or medical form required by Hartford Life and Accident Insurance Company, and that they are full, complete, and true to the best of my knowledge and belief. I understand that any material misrepresentations in this application could cause a claim to be denied under any insurance issued based on this application. I understand that any intent to defraud or knowingly facilitate a fraud against the Company, by submitting an application or filing a claim containing a false or deceptive statement is insurance fraud. I also agree that a copy of this application shall be attached to and form a part of any certificate issued. I also understand that the Company may request whatever additional evidence of insurability it needs. Subject to the deferred effective date provision, I understand that coverage will not become effective until the Company grants its underwriting approval. I do not receive temporary or conditional insurance coverage just because I submit an application and pay the first premium. The Hartford is Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Form PA-9357 (HLA) (CA) IDI648CAE-AGP5541E
6 I authorize any: doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or reinsurer; Medical Information Bureau, Inc.; or employer; to give Hartford Life and Accident Insurance Company or its legal representative information about my/our physical or mental health, (including history, condition, diagnosis and treatment), drug or alcohol use history, other insurance coverage or employment status except drug and alcohol treatment information. Hartford Life and Accident Insurance Company will use the information to decide if and to what extent we are eligible for insurance coverage or benefits under the policy. This information will be treated as confidential. I understand the Medical Information Bureau, Inc. will release records or information only to Hartford Life and Accident Insurance Company. I authorize Hartford Life and Accident Insurance Company to give information about me/us to: its reinsurer(s), the Medical Information Bureau, Inc., any other insurance company to whom I may apply for Life or Health Insurance, or other persons or organizations handling a claim, underwriting coverage applied for or administering coverage issued as a result of this application or as required by law. I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on the authorization. This authorization expires two (2) years from the effective date of my coverage or, if no coverage has been issued one (1) year from the date of this application. I understand that a photocopy of this form is as valid as the original, and that I have a right to receive a copy of this form upon request. I certify that I have received the Notice of Insurance Information Practices. I agree that this document and all its contents shall form a part of my enrollment request for group benefits. PRE-EXISTING CONDITIONS LIMITATION: I understand that any injury or sickness, diagnosed or undiagnosed, for which I have received medical advice or treatment in the 12 month period prior to my effective date of coverage will not be covered until I have gone 12 months ending on or after my effective date of coverage without medical advice or treatment for that condition, or until 1 year after my effective date of coverage, whichever comes first, provided that the condition is not specifically excluded or limited by the policy or by a Health Waiver attached to my certificate. Applications to increase coverage will be subject to a new pre-existing conditions limitation. I further understand that any condition excluded or limited by the Policy or by a Health Waiver attached to my certificate will not be covered under this Policy at any time. Notice: I understand that California law prohibits an HIV test from being required or used by Health Insurance Companies as a condition of obtaining health insurance coverage. Section 9 I wish to pay my premiums: G Automatic Monthly Check Withdrawal G Semi-Annual Direct Bill (If you select Automatic Check Withdrawal, please complete the Automatic Monthly Check Withdrawal Request.) Section 10 Member's signature (Sign name in full) Required Date Required Spouse/Domestic Partner's signature (if applying) Required Date Required Send this completed form to: ADMINISTRATOR MDA GROUP INSURANCE PROGRAM P.O. Box Des Moines, IA mda@marshpm.com The Hartford is Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Form PA-9357 (HLA) (CA) IDI648CAE-AGP5541E 4 * *
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13 Marsh U.S. Consumer, a Service of Seabury & Smith, Inc. P.O. Box Des Moines, IA Administered by: P.O. BOX Des Moines, IA Call: Web: AR Ins. Lic. # CA Ins. Lic. # d/b/a in CA Seabury & Smith Insurance Program Management Underwritten by: Hartford Life and Accident Insurance Company Simsbury, CT (Next page, please)
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Spouse/Domestic Partner's Name: (First, Middle Initial, Last), if applying Spouse/Domestic Partner's Occupation: Basic Monthly Pay: $ Section 4 COVERA
For Members of the American Dental Hygienists' Association TO APPLY: 1. Complete and sign the application. 2. Send no money with your application. You will be billed upon approval. 3. Use the postage paid
Section 5 MEMBER SPOUSE In the last 2 years have you or your Spouse been unable to perform the full-time duties of your occupation for 10 consecutive
HARTFORD LIFE INSURANCE COMPANY Hartford, Connecticut 06155 National Active and Retired Federal Employees Association AGL-1545 Spouse's Name: (First, Middle Initial, Last), if applying Section 4 Amount
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epsmoore_aaa-40471-shorttermrecovery-over65 For Members of AAA GUARANTEED ACCEPTANCE AGP-5382 TO ENROLL: Send this completed form to: ADMINISTRATOR AAA GROUP INSURANCE PROGRAM P.O. BOX 10374 Des Moines,
Thank you for inquiring about the AFA Short Term Recovery Insurance Plan (RecoveryCare).
Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Because Medicare and/or TRICARE For Life simply weren t designed to cover all your Hospital and home recovery care expenses The AFA
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
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HOSPITAL INCOME AND SHORT TERM RECOVERY INSURANCE PLAN CONFIRMATION FORM For Members of the AAA GUARANTEED ACCEPTANCE AGP-5476 SEND NO MONEY NOW! TO ENROLL: Send this completed form to: ADMINISTRATOR AAA
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
GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM
Academy of Nutrition and Dietetics GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM AGP-5177 E (Please make any corrections to your full name and address printed below.) TO ENROLL: Send this completed
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HOSPITAL INCOME AND SHORT TERM RECOVERY INSURANCE PLAN CONFIRMATION FORM For Members of the ASME GUARANTEED ACCEPTANCE 1 PLEASE PRINT IN INK OR TYPE. DO NOT USE CORRECTION FLUID OR GEL PENS. INITIAL AND
Coverage to Help Meet Your Needs!
Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear, The TRICARE Prime Supplement Insurance Plan (MilicarePLUS) insurance protection that continues in the FRA tradition of quality
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. 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
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E American Association of Critical-Care Nurses GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM AGP-1961 (Please make any corrections to your full name and address printed below.) Name: Last First
Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, been positively diagnosed or treated for: chest
To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR NSBA GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-866-236-6582 customerservice.service@mercer.com
Coverage to Help Meet Your Needs!
Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear AFSA Member, The FlightCare TRICARE Prime Supplement Insurance Plan insurance protection that continues in the AFSA tradition of
I understand that the insurance applied for will take effect on the date specified by The United States Life Insurance Company in the City of New York
epsmoore_aao-33015-catastrophemajormedical American Academy of Ophthalmology Please print or type all information requested. NOTE: If you have previously applied for insurance, a copy of that application
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
Medico Medicare Supplement Insurance
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Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated
ADMINISTRATOR CSREA 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
As a Retired Reservist or Shipmate you may have recently become eligible to purchase the TRICARE Retired Reserve Supplement Insurance coverage.
Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear, FRA takes care of its own and now here s the information about the star-spangled FRA membership benefit, TRICARE Retired Reserve
AAA BENEFIT ENROLLMENT FORM AAA Group Accidental Death & Dismemberment Insurance Plan Name: Add 1: Add 2: City, St., Zip: Last First MI After the firs
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Endorsed by: National Active and Retired Federal Employees Association Name: Add 1: Add 2: City, St., Zip: Last First MI TO ENROLL: Send this completed form with your premium check payable to: ADMINISTRATOR
RATE AND BILLING OPTIONS - Please check one: Please select the type of coverage you would like. Enclose a check for the rate selected and mail it with
American Speech-Language-Hearing Association GROUP DENTAL INSURANCE PLAN ENROLLMENT FORM The United States Life Insurance Company in the City of New York TO ENROLL: Send this completed form with your Premium
IMPORTANT: To enroll in this benefit for Retired Reservists, simply complete and sign the enclosed Enrollment Form.
Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear, ROA takes care of its own and now here s the information about the star-spangled ROA membership benefit, TRICARE Retired Reserve
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epsmoore_acbl-41530-shorttermrecovery-over65 American Contract Bridge League ACBL RecoveryCare Plan Simplified Application YOUR ACCEPTANCE IS GUARANTEED. SEND NO MONEY NOW! TO APPLY: Send this completed
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FOR MEMBERS OF THE THE ARC TERM LIFE INSURANCE PLAN ENROLLMENT FORM E TO ENROLL: Send this completed form to: ADMINISTRATOR The Arc GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS?
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Home health care benefits. Just because Medicare or TRICARE "approves" your doctor's recommendation for home health care treatment, they may not cover
imfmoore_roa--shorttermrecovery Office of the Administrator P.O. Box 14464 Des Moines, IA 50306 Dear, Based on your status as an ROA member, you are now eligible for a plan that can provide cash benefits
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APPLICATION FOR GROUP DISABILITY INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Administrative Office: P.O. Box 10374, Des Moines,
RETURN THIS COPY TO JOHN HANCOCK. City/Town: State: Zip:
HIPAA Authorization ATTN: R-02-B Long-Term Care PO Box 852 Boston, MA 02117-0852 Insured Name : Phone: 800-233-1449 Fax: 617-572-7979 Claim Number: Insured Street Address: RETURN THIS COPY TO JOHN HANCOCK
To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever received treatment or been medically a
Endorsed by: American Association of Textile Chemists & Colorists CANCER INSURANCE PLAN APPLICATION FOR RESIDENTS OF WISCONSIN ONLY PLEASE PRINT IN INK OR TYPE. DO NOT USE CORRECTION FLUID OR GEL PENS.
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Endorsed by: American Association of Textile Chemists & Colorists CANCER INSURANCE PLAN APPLICATION FOR RESIDENTS OF KANSAS ONLY PLEASE PRINT IN INK OR TYPE. DO NOT USE CORRECTION FLUID OR GEL PENS. INITIAL
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epsmoore_asist-45065-disability TO APPLY: Complete this form and return with your premium check to: ADMINISTRATOR ASIS&T GROUP INSURANCE PROGRAM P.O. BOX 10374. Des Moines, IA 50306-0374 For residents
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Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear, Thank you for inquiring about the Hawaii State Bar Association Group Insurance Program. Enclosed you'll find the information you
THIS MEMBER BENEFIT OPPORTUNITY, TRICARE SELECT SUPPLEMENT INSURANCE PLAN (FLIGHTCARE), IS RESERVED FOR AIR FORCE MILITARY PERSONNEL ONLY
Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear AFSA Member, THIS MEMBER BENEFIT OPPORTUNITY, TRICARE SELECT SUPPLEMENT INSURANCE PLAN (FLIGHTCARE), IS RESERVED FOR AIR FORCE
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Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with your premium check payable to: NARFE GROUP INSURANCE PROGRAM
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Please answer these brief questions. To the best of your knowledge and belief: 1. During the past 5 years, have you had or been treated for (Circle sp
APPLICATION FOR GROUP DISABILITY INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Administrative Office: P.O. Box 10374, Des Moines,
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Group Term Life Insurance Application Please complete and return this form to: Worldwide Assurance for Employees of Public Agencies (WAEPA) 433 Park Ave., Falls Church, VA 22046 (800)368-3484 www.waepa.org
3. Please read, sign and date: To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever receive
Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with your premium check payable to: AAPSS GROUP INSURANCE PROGRAM
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Thank you. Should you have any questions, please call us at (800)
Dear Policyholder: Please complete and sign the attached claim form. Additionally, the following items are needed in order to process your Medical/Dental claim in the most efficient and expedient way possible.
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Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear, THIS MEMBER BENEFIT OPPORTUNITY, TRICARE SUPPLEMENT INSURANCE PLAN (RESERVECARE), IS RESERVED FOR RESERVE OFFICER PERSONNEL ONLY
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epsmoore_aaa-mn-28018-accidentaldeathanddismemberment To Apply: Complete this form and return to: ADMINISTRATOR AAA GROUP INSURANCE PROGRAM P.O. BOX 10374. Des Moines, IA 50306-0374 For Puerto Rico Residents,
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Request for Group Insurance From: New York Life Insurance Company 51 Madison Ave.. New York, NY 10010 To Apply: Complete This Form And Return To: ADMINISTRATOR AAAS GROUP INSURANCE PROGRAM P.O. Box 10374.
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If you do not have access to a fax machine, send the completed application and any additional documents to:
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