PLEASE CHECK IF THIS IS A REINSTATEMENT OR AN ADDITION.

Transcription

1 REQUEST FOR CHANGE/APPLICATION FOR REINSTATEMENT AND/OR ADDITIONS CANCER INDEMNITY SERIES A76000 ATTENTION: POLICYHOLDER SERVICES (PHS) American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters Columbus, GA For information, call toll-free AFLAC ( ). Fax number Pre-tax After-tax Name of Policyholder SS No. Policy Number Policy Type Date of Birth Associate s/agent's Signature Licensed Resident Associate/Agent Writing Number PLEASE CHECK IF THIS IS A REINSTATEMENT OR AN ADDITION. PLEASE MAKE THE FOLLOWING CHANGES TO MY POLICY ADDRESS CHANGE ONLY New Address of Policyholder Street Apt. No. City State ZIP Telephone No. Former Address of Policyholder Street Apt. No. City State ZIP TRANSFERS TO PAYROLL OR UNION BILLING ONLY Transfer From Transfer To Employer Name Transfer To Account Number Department No. Employee No. Amount Remitted $ Billing Name Months Effective Date of Transfer Form A76003R 1 of 6 A76003R.3

2 TRANSFERS TO DIRECT BILLING ONLY Bill at Home Bankdraft Credit Card Transfer From: Direct Billing Mode (select one) Monthly (Bankdraft / Credit Card Only) Quarterly Semiannual Annual Amount Remitted $ Months Effective Date of Transfer NAME CHANGE ONLY Name Shown on Policy Title Change Name To Title Reason Marriage Divorce Death Request Payroll Billing Name Draftee Name bankdraft) (if policy is on payroll) (if policy is on Effective Date of Change DELETIONS ONLY Person to be Deleted Title Sex Male Female Relationship Insured Spouse Child Reason for Deletion Divorce Death Request Date of Divorce/Death/Request New Policy/Contract Holder s Full Name Sex Male Female Birth Date of New Policy/Contract Holder Billing Name (only applicable if policy on payroll) New Coverage Desired Individual One-Parent Family Two-Parent Family Named Insured/Spouse Only Form A76003R 2 of 6 A76003R.3

3 ADDITIONS ONLY Complete applicable questions listed below. Dependent Children must be under age 25 at the time of application. Person(s) to be Added Title Sex Male Female Relationship Spouse Child DOB of spouse or Dependent Child (other than a newborn) Reason for Addition Marriage Birth Request Date of Marriage/Birth/Request New Coverage Desired One-Parent Family Two-Parent Family Named Insured/Spouse Only REINSTATEMENT OF OR ADDITIONS TO POLICY ONLY Complete applicable questions listed below. ANSWER QUESTIONS 1 THROUGH 5 FOR REINSTATEMENTS OR ADDITIONS ON PAYROLL OR UNION SALES ONLY. 1. Have you or has anyone to be covered had Internal Cancer or an Associated Cancerous Condition that was diagnosed or last treated within the last five years or received preventive hormonal therapy within the last 12 months? Insured/Employee, a policy will not be issued. 2. Have you or has anyone to be covered had Internal Cancer or an Associated Cancerous Condition that was diagnosed or last treated over five years ago? If yes, was it the Named Insured Spouse Child? Name of the child(ren): If yes, please complete a Cancer History Form provided by your associate/agent on any individual(s) listed. You are eligible for a maximum of $5,000 of the Initial Diagnosis Benefit Rider and you are eligible for a maximum of $75 of the Cancer Screening and Annual Care Benefit Rider. If this policy provides higher benefits, then an application for a new lower amount must be completed. 3. Have you or has anyone to be covered had Nonmelanoma Skin Cancer that was diagnosed or last treated within the last five years? If yes, was it the Named Insured Spouse Child? Name of the child(ren) Any person(s) so designated will be issued a Skin Cancer Exclusion Rider. Benefits will not be payable under this policy for the indicated individual for the treatment of Skin Cancer. Proposed Insured s/employee s Initials Form A76003R 3 of 6 A76003R.3

4 ANSWER QUESTIONS 4 AND 5 ONLY IF YOU ARE REINSTATING OR ADDING TO A POLICY WITH MORE THAN $5,000 OF THE INITIAL DIAGNOSIS BENEFIT RIDER OR MORE THAN $75 OF THE CANCER SCREENING AND ANNUAL CARE BENEFIT RIDER: 4. Have you or has anyone to be covered received abnormal test results from a Cancer or Associated Cancerous Condition screening within the past 90 days, or are you or anyone to be covered waiting on the results of medical tests for an undiagnosed condition? 5. Have you or has anyone to be covered used tobacco products or products containing nicotine of any type in the last 12 months? If the answer to either Question 4 or 5 is yes, you are eligible for a maximum of $5,000 of the Initial Diagnosis Benefit Rider and you are eligible for a maximum of $75 of the Cancer Screening and Annual Care Benefit Rider. If this policy provides higher benefits, then an application for a new lower amount must be completed. PLEASE ANSWER THE FOLLOWING QUESTION FOR REINSTATEMENT OF OR ADDITIONS TO THE SPECIFIED-DISEASE RIDER ON PAYROLL OR UNION. Have you or has anyone to be covered under this policy ever had adrenal hypofunction (Addison's disease), ALS (amyotrophic lateral sclerosis) or Lou Gehrig s disease, botulism, bubonic plague, cerebral palsy, cholera, cystic fibrosis, diphtheria, encephalitis (including encephalitis contracted from West Nile virus), Huntington's chorea, malaria, meningitis (bacterial), multiple sclerosis, muscular dystrophy, myasthenia gravis, necrotizing fasciitis, osteomyelitis, polio, rabies, Reye s syndrome, scleroderma, sickle-cell anemia, systemic lupus, tetanus, toxic shock syndrome, tuberculosis, tularemia, typhoid fever, variant Creutzfeldt-Jakob disease (mad cow disease), or yellow fever in any form? Any person(s) so designated above will not be covered under Specified-Disease Rider Form Series A ANSWER QUESTIONS 6 THROUGH 11 FOR REINSTATEMENTS OR ADDITIONS ON NONPAYROLL SALES ONLY. 6. Have you or has anyone to be covered had Internal Cancer or an Associated Cancerous Condition that was diagnosed or last treated within the last ten years or received preventive hormonal therapy within the last 12 months? 7. Have you or has anyone to be covered had Internal Cancer or an Associated Cancerous Condition that was diagnosed or last treated over ten years ago? If yes, please complete a Cancer History Form provided by your associate/agent on any individual(s) listed. Form A76003R 4 of 6 A76003R.3

5 8. Have you or has anyone to be covered had Nonmelanoma Skin Cancer that was diagnosed or last treated within the last ten years? Any person(s) so designated will be issued a Skin Cancer Exclusion Rider. Benefits will not be payable under this policy for the indicated individual for the treatment of Skin Cancer. Proposed Insured s Initials 9. Have you or has anyone to be covered received a health screening (such as a mammogram, Pap smear, PSA, chest X-ray or colonoscopy) that tests for the presence of Cancer or an Associated Cancerous Condition, for which you have not received the results? 10. Have you or has anyone to be covered been advised by a member of the medical profession to receive a follow-up test for the potential presence of Cancer or an Associated Cancerous Condition for which you have not received the results? 11. Within the past 90 days have you or has anyone to be covered received abnormal test results from a health screening test? PLEASE ANSWER THE FOLLOWING QUESTION FOR REINSTATEMENT OF OR ADDITIONS TO THE SPECIFIED-DISEASE RIDER ON NONPAYROLL. Have you or has anyone to be covered under this policy ever had adrenal hypofunction (Addison's disease), ALS (amyotrophic lateral sclerosis) or Lou Gehrig s disease, botulism, bubonic plague, cerebral palsy, cholera, cystic fibrosis, diphtheria, encephalitis (including encephalitis contracted from West Nile virus), Huntington's chorea, malaria, meningitis (bacterial), multiple sclerosis, muscular dystrophy, myasthenia gravis, necrotizing fasciitis, osteomyelitis, polio, rabies, Reye s syndrome, scleroderma, sickle-cell anemia, systemic lupus, tetanus, toxic shock syndrome, tuberculosis, tularemia, typhoid fever, variant Creutzfeldt-Jakob disease (mad cow disease), or yellow fever in any form? Any person(s) so designated above will not be covered under Specified-Disease Rider Form Series A Form A76003R 5 of 6 A76003R.3

6 I understand that the reinstated policy will cover only loss resulting from hospitalization for treatment of Cancer or Associated Cancerous Condition that begins more than ten days after the date of reinstatement. I understand that the information on this form applies ONLY to my Cancer policy. I have read, or had read to me, the completed application and realize policy reinstatement is based upon statements and answers provided herein, and they are complete and true. I understand, for the purposes of the Time Limit on Certain Defenses provision of the policy, that the Effective Date of the policy shall now be the reinstatement date. I also understand that Aflac and I shall have the same rights as provided under the policy(s) immediately before the due date of the defaulted premium, subject to the provisions herein and to any provisions endorsed on or attached to the policy(s) in connection with the reinstatement. I further understand that coverage under the reinstated policy is subject to the terms set forth in my policy(s) reinstatement provision. Signature (X) Signed and Dated at City and State on Date Cafeteria/Section 125 Plans If premiums for your policy are deducted on a pre-tax basis, this section should be completed by your plan administrator. Account Approval Signature: Date: Printed Name: MAKE CHECKS PAYABLE TO AFLAC. FOR INFORMATION, CALL TOLL-FREE AFLAC ( ). VISIT OUR WEB SITE AT AFLAC.COM. Form A76003R 6 of 6 A76003R.3