Dependent Eligibility Verification Affidavit

Transcription

1 Dependent Eligibility Verification Affidavit Dependents who may be covered under your medical benefit plans are one of the following: A child under 26 years of age, which includes natural children, step children & adopted children. Children who are eligible for their own employer-sponsored coverage are not considered eligible dependents for the health insurance plan. Unmarried, totally disabled children over 26 who are incapable of self-sustaining employment as the result of a mental or physical handicap. Please list the dependents that are eligible to be covered under your health insurance plan election. If your spouse is enrolled on both their employer s plan and the COMPANY plan standard coordination of benefit rules will apply for all applicable benefits. Therefore the COMPANY plan will pay spousal claims on a secondary basis for all applicable benefits. Full Name Relationship to Employee Social Security Number Date of Birth Gender Is Child(ren) Eligible for Medical Coverage through their Employer ( / )? Required Required Required Required Required Required If your spouse is enrolled in family coverage on their employer s plan and you are enrolled in family coverage on the COMPANY plan standard coordination of benefit rules will apply. Therefore primary coverage for eligible dependent children will be assigned to the plan of the parent whose birthday occurs earliest in a calendar year. Secondary coverage will be assigned to the plan of the parent whose birthday occurs latest in a calendar year. I certify that the answers provided on this form are true and correct. A person may be committing insurance fraud if he or she submits a form containing a false or deceptive statement with the intent to defraud (or knowing that he or she is helping to defraud). I acknowledge that I am responsible for any future and past claims incurred by ineligible dependents. I understand that, at any time, the COMPANY may require me to provide legal documentation to support my dependents eligibility status. Documents may includge but are not limited to: Marriage Certificates, Birth Certificates, Adoption documents, Proof of Disability, etc. Employee Signature: Date: Failure to provide signature and date will result in coverage not being extended.

2 Reliance Standard Life Insurance Company Enrollment and Statement of Health Name of Employer Location/Division General Health System Policy # and Class # Policy # and Class # Policy # and Class # Policy # and Class # Bill Group VCI / Application Type: Initial Eligibility/New Hire Late Applicant Other Increase Change in Status: Nature of Change(s): Approved Annual Enrollment Date of Change: If marriage, divorce or birth of a child, please provide copy of document. Employee/Member Information Always Complete Submit completed Enrollment and Statement of Health form to: Name Social Security Number Gender Date of Birth Age State of Birth Date of Hire Reliance Standard P.O. Box 7818 Philadelphia, PA We do not accept faxed forms. Address City State Zip Phone Number Occupation Annual Compensation Hours Worked Per Week Address Are you actively performing all the duties of your occupation or profession? If, explain: Coverage Elected and Amounts Coverage Voluntary Critical Illness: Employee Enroll or Decline 1 Enroll Decline 1 "Enroll" authorizes employer to payroll deduct premiums. Current Amount Increase or Decrease +$ -$ Total Amount Applied For $ Monthly Premium See Premium Table LRS Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA Page 1 of 3

3 Employee/Member Name Date of Birth Health Questions Answer all questions on this page for each person being underwritten for insurance. For any "" answer, underline the condition and record details in the space provided on the next page. Failure to provide details of a condition will cause a delay in the review of your application. Enter height and weight. 1. In the past 10 years, have you been treated for or diagnosed as having: heart, liver (biliary cirrhosis) or kidney disorder; an abnormal colonoscopy requiring follow-up; neurological disorder; diabetes; high blood pressure; thyroid disorder; stroke; transient ischemic attack (TIA); cancer and/or tumor malignant or benign; mental or nervous disorder; or been advised to have treatment for drug abuse (illegal or prescription drugs) or alcoholism? 2. In the past 10 years, have you been diagnosed with or treated for: chronic pain; arthritis (lupus, rheumatoid or osteoarthritis); musculoskeletal (back, neck or muscle) condition; respiratory disorder including asthma, chronic obstructive pulmonary disease (COPD); or emphysema? 3. Have you: (a) in the past year had: fever persisting more than one month; significant involuntary weight loss; diarrhea persisting more than one month; oral candidiasis (thrush); or lymphadenopathy (enlarged or swollen glands)? or (b) in the past 10 years ever tested positive or been treated for HIV (Human Immunodeficiency Virus) antibodies, AIDS or AIDS-related complex (ARC)? 4. In the past 10 years, have you: (a) consulted with or been examined or treated by a physician, practitioner or specialist (include routine physicals only when there is an existing or newly diagnosed medical condition)? (b) been in a hospital or other facility for observation, diagnosis, treatment or an operation? or (c) been prescribed medication(s) (other than for colds, flu or allergies)? 5. Are you currently pregnant? In the past 10 years, have you been diagnosed with: abnormal uterine bleeding; abnormal pap smear; abnormal mammogram requiring additional studies or with recommendation of breast biopsy? Answer question 6 only if applying for Critical Illness insurance. 6. Have two or more of your biological parents, brothers or sisters (either living or dead) been diagnosed with the same condition from the following list of conditions: diabetes, heart disease, stroke, kidney disease or cancer (other than skin cancer)? EMPLOYEE Ht. ft. in. Wt. lbs Employee/Member Primary Care Physician's Full Name Office Phone Number Address LRS Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA Page 2 of 3

4 Employee/Member Name Date of Birth Details Please provide all names used for medical records (if different than the names provided on this form): For each response to a health question, please provide details below. Question # Illness or Nature of Injury Date Physician s Full Name and Address (if different than Primary) If you need more space, check here. Complete, sign and date a separate sheet of paper and attach it to this page. Read, Sign and Date Below I understand and agree that: The information provided on this Enrollment and Statement of Health form is true and correct to the best of my knowledge. The insurance requested will become effective in accordance with the individual effective date information in the Policy; any amount subject to evidence of insurability will not become effective until approved by Reliance Standard and Reliance Standard has the right to refuse my request. Coverage is subject to a minimum participation requirement at the employer level and if the minimum is not met, coverage may not be issued even though an enrollment form has been completed. An effective date is subject to eligibility requirements, satisfaction of service waiting period (if applicable) and payment of first premium when due. An effective date may be deferred for an employee not actively at work and enrolled dependents confined to a hospital or at home. Benefits are subject to terms and conditions of the Policy. For age-banded rate plans, premiums increase as an employee moves from one age band to the next. If payroll deduction of premiums begins prior to Reliance Standard s processing of the enrollment form, it does not mean coverage is in effect; premiums paid for coverage not issued will be returned. I further understand and agree that if I am applying after the expiration of my initial eligibility period, all medical tests and costs for attending physician reports may be without expense to Reliance Standard Life Insurance Company and I may be responsible for paying the expenses, if any. I acknowledge receipt of the "Designation of Beneficiary" form and Important Information Regarding Applications for Insurance and tice Regarding Information Practices. If a Designation of Beneficiary form is not completed or one is not on file with the Plan Administrator, the provisions of the Policy will determine to whom benefits, if any, will be payable. AUTHORIZATION: I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, organization, institution, person or the MIB, Inc. to release any information or record(s) on me or my health to be used in determining the acceptability of my application for insurance. I authorize any such information or record(s) to be released to Reliance Standard Life Insurance Company, its reinsurers or authorized representatives. I also authorize Reliance Standard or its reinsurers to make a brief report of my personal health information to the MIB. This authorization, or a photographic copy, shall be as binding as the original and valid for a period not exceeding twelve (12) months from this date. I understand that I (or my authorized representative) will be sent a copy of this Authorization upon request. Please te: During an approved enrollment, guaranteed issue amounts of insurance will not require a Statement of Health form provided the Enrollment form is complete, signed and received by your employer during your enrollment period and: a) you are not a late applicant with respect to insurance for yourself; or b) during your present service with your employer or an affiliate, you have not, with respect to insurance with Reliance Standard or an affiliate: had an application withdrawn; been previously declined; had coverage postponed; or voluntarily terminated; or c) the enrollment period is not one with specific guaranteed issue/health acceptability rules. X Employee s/member's Signature (required at all times) Date LRS Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA Page 3 of 3

5 Designation of Beneficiary Policyholder Policy Number(s) Insured Name Social Security Number I hereby designate the following as my beneficiary (ies) under the above policy number(s): Primary Beneficiary(ies) Full Name and Address (Please Print) Percentage* (Must total 100%) Date of Birth Relationship Social Security Number * If no percentages are indicated, benefits will be divided equally between all primary beneficiaries. Contingent Beneficiary(ies) (applicable only if you are not survived by one or more primary beneficiaries) Full Name and Address (Please Print) Percentage* (Must total 100%) Date of Birth Relationship Social Security Number * If no percentages are indicated, any benefits payable to contingent beneficiaries will be divided equally between all contingent beneficiaries. This beneficiary designation revokes all revocable prior beneficiary designations. Unless you indicate otherwise, if any beneficiary predeceases you, that beneficiary's share will be divided pro-rata among the surviving beneficiaries of the same class (primary or contingent). If no beneficiary (primary or contingent) survives you, payment will be made pursuant to the terms of the applicable policy. Date Signature of Insured

6 Important Information Regarding Applications for Insurance The information provided on the Enrollment and Statement of Health form will be used in determining the insurability of a person proposed for insurance. Responsible parties completing and submitting a Statement of Heath form are required to be made aware of the following statements concerning the consequences of insurance fraud. The lack of an applicable statement shall not constitute a defense against penalties. ARKANSAS and LOUISIANA 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. 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. 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. KENTUCKY Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. MAINE 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 benefits. MARYLAND Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who 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. NEW JERSEY Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW MEXICO Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefits 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. NEW YORK (health insurance only) 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO Any person who, with intent to defraud or knowing that he 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 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. TENNESSEE, VIRGINIA, 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 benefits. WASHINGTON, DC 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. KEEP THIS INFORMATION PAGE FOR YOUR RECORDS. Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania

7 NOTICE REGARDING INFORMATION PRACTICES In considering this Application, Reliance Standard Life Insurance Company ("we", "us" or "our") collects certain information about all proposed insureds ("you" or "your"). The precise information varies according to the amount and type of coverage you apply for. Generally, we seek information about your: (1) age; (2) occupation; (3) physical condition; (4) medical history; (5) hobbies; and (6) other relevant activities. You are the most important source of information, but we may also verify or collect information on you or your family from: (1) physicians; (2) other health care providers; (3) employers; (4) other insurers to which you have applied; (5) consumer investigative organizations; and (6) the MIB, Inc. The MIB is a not-for-profit organization of life insurance companies which operates an information exchange for its members. This information may alert us to a need for further investigation, but under MIB rules such information cannot be used: (1) either wholly or in part to increase the premium for insurance; or (2) to deny issuance of insurance. We may collect information by: (1) phone; (2) correspondence; or (3) personal contact. Information will be treated as confidential. Reliance Standard Life Insurance Company or its reinsurers may, however, with your authorization make a brief report to the MIB. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply such company with the information in its file. The information supplied to other member companies may alert them to a need for further investigation. In some circumstances, however, information may be released to third parties without your authorization (with the exception of the MIB). These include persons or organizations who are: (1) performing business functions for us; (2) conducting actuarial or scientific studies or audits; or (3) our reinsurers. We or our reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance coverage, or to whom a claim for benefits is submitted. Please be assured that although such disclosures may occur, they are not always or even often made. When a disclosure is necessary, only as much information as is reasonably necessary to achieve the intended purpose will be disclosed. You have the right to acquire and, if necessary, correct any personal information we or the MIB collect. Upon written request to us, we will within 30 days of receipt: (1) inform you of the nature and substance of the recorded information; (2) permit personal viewing and copying of the information in our possession; (3) disclose the identities of those persons such information has been disclosed to within the last two years; and (4) provide you with procedures for correction, amendment or deletion of the recorded information. Medical information will be disclosed to a physician that you choose. You may write to us for a fuller explanation of our information practices. You may also contact the MIB via its website ( or by telephone to arrange for disclosure of any information it may have on you. The MIB's toll-free telephone number is If you question the accuracy of information in the MIB's file, you may contact the MIB in writing and seek correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts KEEP THIS NOTICE FOR YOUR RECORDS. Home Office: Administrative Office: Chicago, Illinois Philadelphia, Pennsylvania

8 Reliance Standard Life Insurance Company Enrollment and Statement of Health Name of Employer Location/Division General Health System Policy # and Class # Policy # and Class # Policy # and Class # Policy # and Class # Bill Group VPS / Application Type: Initial Eligibility/New Hire Late Applicant Other Increase Change in Status: Nature of Change(s): Approved Annual Enrollment Date of Change: If marriage, divorce or birth of a child, please provide copy of document. Employee/Member Information Always Complete Submit completed Enrollment and Statement of Health form to: Name Social Security Number Gender Date of Birth Age State of Birth Date of Hire Reliance Standard P.O. Box 7818 Philadelphia, PA We do not accept faxed forms. Address City State Zip Phone Number Occupation Annual Compensation Hours Worked Per Week Address Are you actively performing all the duties of your occupation or profession? If, explain: Coverage Elected and Amounts Coverage Voluntary STD: Employee 2 Enroll or Decline 1 Enroll Decline 1 "Enroll" authorizes employer to payroll deduct premiums. 2 Statement of Health may be required. Current Amount Increase or Decrease +$ per Week -$ per Week Total Amount Applied For $ per Week Monthly Premium See Premium Table LRS Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA Page 1 of 3

9 Employee/Member Name Date of Birth Health Questions Answer all questions on this page for each person being underwritten for insurance. For any "" answer, underline the condition and record details in the space provided on the next page. Failure to provide details of a condition will cause a delay in the review of your application. Enter height and weight. 1. In the past 10 years, have you been treated for or diagnosed as having: heart, liver (biliary cirrhosis) or kidney disorder; an abnormal colonoscopy requiring follow-up; neurological disorder; diabetes; high blood pressure; thyroid disorder; stroke; transient ischemic attack (TIA); cancer and/or tumor malignant or benign; mental or nervous disorder; or been advised to have treatment for drug abuse (illegal or prescription drugs) or alcoholism? 2. In the past 10 years, have you been diagnosed with or treated for: chronic pain; arthritis (lupus, rheumatoid or osteoarthritis); musculoskeletal (back, neck or muscle) condition; respiratory disorder including asthma, chronic obstructive pulmonary disease (COPD); or emphysema? 3. Have you: (a) in the past year had: fever persisting more than one month; significant involuntary weight loss; diarrhea persisting more than one month; oral candidiasis (thrush); or lymphadenopathy (enlarged or swollen glands)? or (b) in the past 10 years ever tested positive or been treated for HIV (Human Immunodeficiency Virus) antibodies, AIDS or AIDS-related complex (ARC)? 4. In the past 10 years, have you: (a) consulted with or been examined or treated by a physician, practitioner or specialist (include routine physicals only when there is an existing or newly diagnosed medical condition)? (b) been in a hospital or other facility for observation, diagnosis, treatment or an operation? or (c) been prescribed medication(s) (other than for colds, flu or allergies)? 5. Are you currently pregnant? In the past 10 years, have you been diagnosed with: abnormal uterine bleeding; abnormal pap smear; abnormal mammogram requiring additional studies or with recommendation of breast biopsy? EMPLOYEE Ht. ft. in. Wt. lbs Employee/Member Primary Care Physician's Full Name Office Phone Number Address LRS Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA Page 2 of 3

10 Employee/Member Name Date of Birth Details Please provide all names used for medical records (if different than the names provided on this form): For each response to a health question, please provide details below. Question # Illness or Nature of Injury Date Physician s Full Name and Address (if different than Primary) If you need more space, check here. Complete, sign and date a separate sheet of paper and attach it to this page. Read, Sign and Date Below I understand and agree that: The information provided on this Enrollment and Statement of Health form is true and correct to the best of my knowledge. The insurance requested will become effective in accordance with the individual effective date information in the Policy; any amount subject to evidence of insurability will not become effective until approved by Reliance Standard and Reliance Standard has the right to refuse my request. Coverage is subject to a minimum participation requirement at the employer level and if the minimum is not met, coverage may not be issued even though an enrollment form has been completed. An effective date is subject to eligibility requirements, satisfaction of service waiting period (if applicable) and payment of first premium when due. An effective date may be deferred for an employee not actively at work and enrolled dependents confined to a hospital or at home. Benefits are subject to terms and conditions of the Policy. For age-banded rate plans, premiums increase as an employee moves from one age band to the next. If payroll deduction of premiums begins prior to Reliance Standard s processing of the enrollment form, it does not mean coverage is in effect; premiums paid for coverage not issued will be returned. I further understand and agree that if I am applying after the expiration of my initial eligibility period, all medical tests and costs for attending physician reports may be without expense to Reliance Standard Life Insurance Company and I may be responsible for paying the expenses, if any. I acknowledge receipt of Important Information Regarding Applications for Insurance and tice Regarding Information Practices. AUTHORIZATION: I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, organization, institution, person or the MIB, Inc. to release any information or record(s) on me or my health to be used in determining the acceptability of my application for insurance. I authorize any such information or record(s) to be released to Reliance Standard Life Insurance Company, its reinsurers or authorized representatives. I also authorize Reliance Standard or its reinsurers to make a brief report of my personal health information to the MIB. This authorization, or a photographic copy, shall be as binding as the original and valid for a period not exceeding twelve (12) months from this date. I understand that I (or my authorized representative) will be sent a copy of this Authorization upon request. Please te: During an approved enrollment, guaranteed issue amounts of insurance will not require a Statement of Health form provided the Enrollment form is complete, signed and received by your employer during your enrollment period and: a) you are not a late applicant with respect to insurance for yourself; or b) during your present service with your employer or an affiliate, you have not, with respect to insurance with Reliance Standard or an affiliate: had an application withdrawn; been previously declined; had coverage postponed; or voluntarily terminated; or c) the enrollment period is not one with specific guaranteed issue/health acceptability rules. X Employee s/member's Signature (required at all times) Date LRS Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA Page 3 of 3

11 Important Information Regarding Applications for Insurance The information provided on the Enrollment and Statement of Health form will be used in determining the insurability of a person proposed for insurance. Responsible parties completing and submitting a Statement of Heath form are required to be made aware of the following statements concerning the consequences of insurance fraud. The lack of an applicable statement shall not constitute a defense against penalties. ARKANSAS and LOUISIANA 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. 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. 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. KENTUCKY Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. MAINE 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 benefits. MARYLAND Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who 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. NEW JERSEY Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW MEXICO Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefits 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. NEW YORK (health insurance only) 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO Any person who, with intent to defraud or knowing that he 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 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. TENNESSEE, VIRGINIA, 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 benefits. WASHINGTON, DC 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. KEEP THIS INFORMATION PAGE FOR YOUR RECORDS. Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania

12 NOTICE REGARDING INFORMATION PRACTICES In considering this Application, Reliance Standard Life Insurance Company ("we", "us" or "our") collects certain information about all proposed insureds ("you" or "your"). The precise information varies according to the amount and type of coverage you apply for. Generally, we seek information about your: (1) age; (2) occupation; (3) physical condition; (4) medical history; (5) hobbies; and (6) other relevant activities. You are the most important source of information, but we may also verify or collect information on you or your family from: (1) physicians; (2) other health care providers; (3) employers; (4) other insurers to which you have applied; (5) consumer investigative organizations; and (6) the MIB, Inc. The MIB is a not-for-profit organization of life insurance companies which operates an information exchange for its members. This information may alert us to a need for further investigation, but under MIB rules such information cannot be used: (1) either wholly or in part to increase the premium for insurance; or (2) to deny issuance of insurance. We may collect information by: (1) phone; (2) correspondence; or (3) personal contact. Information will be treated as confidential. Reliance Standard Life Insurance Company or its reinsurers may, however, with your authorization make a brief report to the MIB. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply such company with the information in its file. The information supplied to other member companies may alert them to a need for further investigation. In some circumstances, however, information may be released to third parties without your authorization (with the exception of the MIB). These include persons or organizations who are: (1) performing business functions for us; (2) conducting actuarial or scientific studies or audits; or (3) our reinsurers. We or our reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance coverage, or to whom a claim for benefits is submitted. Please be assured that although such disclosures may occur, they are not always or even often made. When a disclosure is necessary, only as much information as is reasonably necessary to achieve the intended purpose will be disclosed. You have the right to acquire and, if necessary, correct any personal information we or the MIB collect. Upon written request to us, we will within 30 days of receipt: (1) inform you of the nature and substance of the recorded information; (2) permit personal viewing and copying of the information in our possession; (3) disclose the identities of those persons such information has been disclosed to within the last two years; and (4) provide you with procedures for correction, amendment or deletion of the recorded information. Medical information will be disclosed to a physician that you choose. You may write to us for a fuller explanation of our information practices. You may also contact the MIB via its website ( or by telephone to arrange for disclosure of any information it may have on you. The MIB's toll-free telephone number is If you question the accuracy of information in the MIB's file, you may contact the MIB in writing and seek correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts KEEP THIS NOTICE FOR YOUR RECORDS. Home Office: Administrative Office: Chicago, Illinois Philadelphia, Pennsylvania

13 INSURANCE ENROLLMENT FORM Life Insurance Company of rth America (LINA) a CIGNA Company (herein called the Insurance Company) The applicant must sign and date this form. EMPLOYER General Health Systems Important: Please enter all dates in mm/dd/yyyy format. Please print (preferably in black ink) EMPLOYEE SECTION Mr. Mrs. Ms. (Check One) Employee Name Social Security # Birthdate Address City State Zip Work Phone Home Phone Employee ID # Sex: M F Important: You must complete the medical questions in this application if you apply for life insurance: (1) as a newly hired employee you are applying more than 31 days after you are eligible to elect benefits; (2) you were eligible under the prior plan and enroll or increase your insurance amount(s) after the completion of the Initial Enrollment period. COMPLETE IF ELECTING SPOUSE COVERAGE I am currently married and my date of marriage is Spouse Name (First) (Last) Social Security # Information Birthdate Sex: M F Voluntary Employee-Paid Coverage Applicant Employee Spouse Child(ren) Decline TERM LIFE INSURANCE POLICY NO. FLX Requested Amount Guaranteed Coverage Amount* times salary $250,000 $10,000 Number of $ 10,000 units $10,000 Number of $ 5,000 units $5,000 *Guaranteed Coverage Amount is only available during Initial Enrollment and at such other times as identified and outlined in offering materials. Amounts of insurance may be limited by state law. ACCIDENT INSURANCE POLICY NO. OK I select the following insurance amount: Employee Benefit Amount: times salary $10,000 ACCEPTANCE/DECLINATION I accept the insurance coverages elected above. If premiums are to be paid by payroll, I authorize my employer to deduct the necessary amounts from my earnings. If I have not elected coverage, I understand that if I wish to participate at a later date, I may be required to furnish evidence of insurability at my own expense and that coverage is subject to the insurance company's approval. Signature Date Please Sign Here See next page for Beneficiary Designation Return this form to your employer. Be sure to make a copy for your own records. 10/2012

14 Applicant s Name Social Security # BENEFICIARY To specify a beneficiary, complete the section below. You will be the beneficiary for your spouse and child(ren) unless you specify otherwise. When specifying multiple beneficiaries, you must indicate the percentage of distribution for each. If there is not enough room to specify all beneficiaries, attach, sign and date a separate sheet of paper using the format below. TERM LIFE INSURANCE POLICY NO. FLX Insured Beneficiary Percentage Social Security # Date of Birth Relationship Employee Spouse Child(ren) ACCIDENT INSURANCE POLICY NO.OK Insured Beneficiary Percentage Social Security # Date of Birth Relationship Employee Spouse Child(ren) Community Property Laws If you are married, reside in a community property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin), and name someone other than your spouse as beneficiary payment of benefits may be delayed or disputed unless your spouse also signs the beneficiary designation. Spouse Signature Date Owner Signature Date GUIDELINES FOR DESIGNATION OF BENEFICIARIES General - Please be sure to include the beneficiary s full name, social security number and relationship to you. Providing this information can help expedite the claim process by making it easier to locate and verify beneficiaries. Minors - While you may designate minors as beneficiaries, please note that claim payments may be delayed due to special issues raised by these designations. In the event of a claim and the beneficiary is a minor child, the insurance proceeds will not be released to the minor child. The insurance proceeds may be paid to a duly appointed guardian of the child s estate. You may want to obtain the assistance of an attorney in drafting your beneficiary designation. Trust as Beneficiary - You may designate a trust as beneficiary, using the following form: To [name of trustee], trustee of the [name of trust], under a trust agreement dated [date of trust]. If you wish to designate a testamentary trust as beneficiary (i.e., one created by will), you should recognize the possibility that your will, which was intended to create this trust, may not be admitted to probate (because it is lost, contested, or superseded by a later will). Claim payment delays can result if the beneficiary designation doesn t provide for this situation. Life Status Changes - We recommend that you review your beneficiary designation when significant life status events occur, such as marriage, divorce, or birth of a child. See an Attorney! The above guidelines are general and are not intended to be relied on as legal advice. Unless your designation is a simple one, we recommend that you obtain the assistance of an attorney in drafting your beneficiary designation. A qualified attorney can help assure that your beneficiary designation correctly reflects your intentions, is clear and unambiguous, and meets legal requirements. Return this form to your employer. Be sure to make a copy for your own records.

15 AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA For AHL Home Office use only tes EVIDENCE OF INSURABILITY AND ENROLLMENT FORM Check appropriate box(es) Group Voluntary Accident Group Voluntary Hospital Indemnity Group Voluntary Cancer/Specified Disease Heritage Choice Dental (enrollment only) Please print with black ink EMPLOYEE S NAME Last (Sr, Jr, etc) First M.I. HOME ADDRESS (Street or P.O. Box) GENERAL INFORMATION SECTION (Please complete entire section for all coverages) SEX SOCIAL SECURITY NUMBER Married Single CITY STATE ZIP BIRTHDAY (MM/DD/YEAR) PHONE NUMBER EMPLOYER DATE OF HIRE (MM/DD/YEAR) GROUP POLICY NAME (If different from the employer name) HEIGHT WEIGHT CURRENT EARNINGS JOB TITLE BENEFICIARY S NAME (Last, First, M.I.) PLANT OR DIVISION RELATIONSHIP Are you changing any of your existing coverage due to a qualifying event such as marriage, birth, or adoption? Group Voluntary Cancer/Specified Disease Group Voluntary Hospital Indemnity If, please complete the following: Date of Qualifying Event Do you wish to terminate this coverage? Qualifying Event Current Certificate Number Do you currently have any of the following individual products with AHL? Cancer Accident Hospital Indemnity If you answered to any of the products, please enter the Policy Number Choose Plan(s): Accident Cancer Hospital Dental Dependent s Name(s) (Last, First, M.I.) $ Hourly Weekly Bi-weekly (26) Heritage Choice Dental Group Voluntary Accident (also check appropriate box) If, please enter effective date of termination DEPENDENT COVERAGE SECTION (Please complete if dependent coverage elected. Use additional paper if needed.) Spouse Child Child Child Child Sex Date of Birth (MM/DD/YEAR) Monthly Semi-monthly (24) Annually Social Security Number Premium/Billing Mode Case Number Agent Number Percentage Credit Monthly Semi-monthly Bi-weekly Weekly Other Employee Number Date of First Deduction Cash With Application Situs State AWD4502LA Page 1 of 4 (05/04)

16 EVIDENCE OF INSURABILITY AND ENROLLMENT FORM SELECTION OF COVERAGE SECTION (Answer or and complete for each coverage selected) Accident Base Units Employee Only Family Section 125 Total Mode Premium $ Optional Disability Riders for Employee Off the Job Accident On and Off the Job Accident Optional Disability Riders for Spouse On and Off the Job Accident for Insured Spouse* Off the Job Accident and Sickness On and Off the Job Accident and Sickness On and Off the Job Accident and Sickness for Insured Spouse* *Available only when family coverage is selected and the insured spouse has worked 25 hours per week for 3 or more consecutive months. Disability Rider Units Employee Spouse Cancer/Specified Disease Benefits Units Hospital Radiation / Chemotherapy Plan Surgery Related Employee Only Family Misc. 1 Initial Diagnosis Option Section 125 Intensive Care Option Total Mode Premium $ Cancer Screening Option Hospital Indemnity Benefits Units Hospital Related Surgery / Inpatient Physician Plan Outpatient Related Employee Only Employee+Spouse Employee+Child(ren) Family Diagnostic / Wellness Option Section 125 Prescription Drug Option Total Mode Premium $ Disability Rider 1 Life Rider Heritage Choice Dental Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Were you covered under your Employer s prior Dental Plan? Employee Only Section 125 Total Mode Premium Employee+Spouse Employee+Child $ Family AHL Home Office Use Only If, please enter the date coverage effective P1NG1 P1NG2 P1NG3 AWD4502LA Page 2 of 4 (05/04)

17 EVIDENCE OF INSURABILITY AND ENROLLMENT FORM EVIDENCE OF INSURABILITY SECTION (Please complete each question applicable to coverages selected. Does not apply to Dental.) n-medical Questionnaire 1. All Is any person to be insured actively at work now and has he/she worked at least 20 hours each week Coverages performing all duties at his/her regular occupation at his/her regular place of employment for the last 3 months except for minor illness or injury of 1 week or less, or normal pregnancy? If any of the questions 2-8 below are answered yes, please list the required health history on the next page. All Coverages Accident Riders Only Accident & Sickness Disability Riders Cancer Intensive Care Optional Benefit (Cancer Only) Hospital Indemnity 2. Is any person to be insured now being treated, or ever been treated or diagnosed by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC), or ever tested positive for antigens or antibodies to an AIDS virus? 3. Has any person to be insured, in the last 3 years, had his/her driver s license suspended or revoked or been arrested for reckless or drunken driving and/or been involved in 3 or more motor vehicle accidents? If yes, provide additional details on the next page. 4a. Has any person to be insured, within the last 2 years, had, been treated for, or been told by a member of the medical profession that he/she has: diabetes, emphysema, asthma, epilepsy, hepatitis, mental or nervous illness, ulcers, any disorder of the central nervous system (to include muscular dystrophy or multiple sclerosis); Parkinson s Disease; lupus; rheumatoid arthritis; fibromyalgia; chronic fatigue syndrome; any disorder of the heart, kidneys, liver, lungs, pancreas or back; paralysis; optic neuritis; cancer (except basal cell skin cancer), malignant tumor, leukemia, Hodgkin s Disease; or stroke? b. Has any person to be insured been diagnosed with hypertension or high blood pressure? c. If the answer to [4b] is yes, in the last year has he/she had either: (1) a systolic blood pressure reading higher than 150 more than once; or (2) a diastolic blood pressure reading higher than 100 more than once? d. Has any person to be insured, in the last 2 years, been treated for or counseled for alcohol or drug abuse? e. Has any person to be insured had any medical or surgical procedures (including organ transplant) advised or recommended by a doctor but not done at this time? 5. Is any person to be insured currently undergoing any diagnostic test for, now being treated for, or ever been treated for, cancer or any malignancy which includes: carcinoma; sarcoma; Hodgkin s Disease; leukemia; lymphoma; or any malignant tumor? 6a. Is any person to be insured now being treated for, or ever been treated for: a stroke; a heart attack; a heart condition; heart trouble; or any abnormality of the heart (including artery disease)? b. Has any person to be insured been diagnosed with hypertension or high blood pressure? c. 7a. b. c. If the answer to [6b] is yes, in the last year has he/she had either: (1) a systolic blood pressure reading higher than 150 more than once; or (2) a diastolic blood pressure reading higher than 100 more than once? Is any person to be insured currently being treated for, or has any person ever been treated for, cancer or any malignancy which includes: carcinoma; sarcoma; Hodgkin s Disease; leukemia; lymphoma; or any malignant tumor; a stroke; a heart attack; a heart condition; heart trouble; any abnormality of the heart (including artery disease); or diabetes? Has any person to be insured been diagnosed with hypertension or high blood pressure? If the answer to [7b] is yes, in the last year has he/she had either a: (1) systolic blood pressure reading higher than 150 more than once or (2) diastolic blood pressure reading higher than 100 more than once? Hospital Indemnity 8. Has any person to be insured, within the last 3 years, been treated for, or been told by a member of the medical profession that he or she has: epilepsy; hepatitis; muscular dystrophy or muscular sclerosis or any disorder of the central nervous system; Parkinson s Disease; lupus; any disorder of the kidneys, liver, lungs; paralysis; been counseled for alcohol or drug abuse; or had any medical or surgical procedure recommended but not done at this time? AWD4502LA Page 3 of 4 (05/04)

18 EVIDENCE OF INSURABILITY AND ENROLLMENT FORM REQUIRED HEALTH HISTORY *Include diagnosis, dates, and duration along with names and addresses of all attending physicians and medical facilities. PERSON REASON Nature of any illness, injury, or diagnosis DATES Including duration of illness NAMES AND ADDRESSES OF HOSPITALS AND/OR PHYSICIANS Use this space for any additional explanation of questions 2-8 on page 3. Indicate the applicable question number and person to whom it applies. Use additional paper if needed. CERTIFICATION, UNDERSTANDING AND AUTHORIZATIONS I CERTIFY that the statements and answers contained on this form are made by me, are complete and true, are correctly and fully recorded and that no important circumstance or information has been withheld or omitted. These statements and answers are offered to American Heritage Life Insurance Company as an inducement to grant insurance, and I understand that American Heritage Life Insurance Company may use misstatements or misrepresentations to contest the validity of any coverage provided on the basis of this evidence of insurability. FRAUD NOTICE: 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. I UNDERSTAND that the effective date of my elected coverages will be the effective date recorded on the Certificate, not the date this Evidence of Insurability form is signed. I AUTHORIZE any physician, medical practitioner, hospital, clinic or other medical facility, insurance company, or other organization, institution or person, that has records or knowledge of me or my health to to give to American Heritage Life, it s subsidiaries or its reinsurers any information. I acknowledge receipt of the Important tice About Privacy. A copy of this authorization is as valid as the original. This authorization applies to any dependent on whom insurance is requested. This authorization is valid for a period of 24 months from the date signed. I understand that I may revoke this authorization at any time by notifying American Heritage Life in writing of my desire to do so. I ALSO AUTHORIZE my employer to deduct from my salary or wages, if applicable, the necessary premium for the coverages requested above. This signature also verifies the accuracy of the information on this enrollment form. I understand that if I refuse any coverage for which I am eligible, satisfactory proof of insurability may be required, at my own expense, should I desire to apply for it at a later date. Any such application may be declined on the basis of such proof. Employee s Signature Signed at Date Signed (City and State) AWD4502LA Page 4 of 4 (05/04)