Employee Enrollment Application

Transcription

1 Employee Enrollment Application Your Anthem enrollment application is inside. It is essential that you read it carefully and complete all necessary sections. If you are a new enrollee }} Applying for health, vision and/or dental benefits, please complete Sections 1, 3, 4, 5, 6, 7, 8 and 9. Your signature is required in Section 9. }} Waiving any or all benefits, please complete Sections 1, 4, and 10. Your signature is required in Section 10. If you are adding a dependent(s) Complete Section 2 in addition to the above. It is important that you read and understand the Significant Terms, Conditions and Authorizations in Section 9. Thank you for choosing Anthem Blue Cross and Blue Shield. Note: You may be required to supply additional information. Anthem provides administrative claims payment services only, and does not assume any financial risk or obligation with respect to claims. A-77 LG-ASO Rev. 12/10 Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin ( BCBSWi ), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ( Compcare ), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. Page 1 of 5

2 Enrollment Application Anthem provides administrative claims payment services only, and does not assume any financial risk or obligation with respect to claims. Please complete this form in ink and return to your employer. Use extra sheets of paper if necessary. All information given should apply to this employer. Anthem s Primary Care Physician (PCP) listings, for HMO/POS products can be obtained through EMPLOYER USE ONLY Group no. Sub-group no. Applicant no./dept. name Request effective date (MM/DD/YYYY) Employer name Address (please include suite no., city, state, ZIP code) ANTHEM USE ONLY Plan PCP COB Health effective date (MM/DD/YYYY) Dental effective date (MM/DD/YYYY) Vision effective date (MM/DD/YYYY) Pre-ex date (MM/DD/YYYY) Section 1. REASON FOR APPLICATION m New enrollment m Waiver m Add dependent (see Section 2) m Rehire (event date) m New hire m Annual open enrollment m COBRA Qualifying event m Conversion (event date) Section 2. STATUS CHANGE/EVENT m Event date (MM/DD/YYYY) m Marriage m Birth m Adoption* m Legal guardianship* m Other *Include legal documentation. Section 3. TYPE OF COVERAGE/PLAN Health coverage Dental coverage Vision coverage m HMO* 1 (except Ohio) m EPO (Ohio only) m PPO m POS m Blue Traditional m Anthem Essential SM Choice PPO m Blue Access SM Hospital Surgical PPO (IN, KY, OH only) m Blue Access SM Choice Hospital Surgical PPO (MO only) m Blue Preferred ASO/EPO m Lumenos Health Savings Account m Lumenos Health Reimbursement Account m Lumenos Health Incentive Account m Lumenos Health Incentive Account Plus m Anthem Essential SM PPO m Anthem Essential SM Select (MO only) m Blue Access SM Hospital Surgical PPO (MO only) m Blue Preferred Select (MO only) m Blue Preferred Plus Hospital Surgical POS (WI only) 1 Ohio only-a health insuring corporation product or HIC Anthem will facilitate the opening of a Health Savings Account in your name, if directed by your Employer. m PPO m Traditional (IN, OH only) m Dental Blue 100/200/300 m Dental Blue 100 m Vision m Employee only m Employee and spouse m Employee and child(ren) m Family coverage m No coverage m Employee only m Employee and spouse m Employee and child(ren) m Family coverage m No coverage m Employee only m Employee and spouse m Employee and child(ren) m Family coverage m No coverage Section 4. EMPLOYEE INFORMATION (*Only complete Primary Care Physician (PCP) information when enrolling in HMO or POS products.) Social security no. (required) Last name First name M.I. Age Date of birth (MM/DD/YYYY) Home address (street, city, state, ZIP code) County (KY residents include municipality) m Single m Divorced m Married Sex m M m F Home phone Work phone address Are you retired? Are you disabled? Are you hospitalized? Occupation Full-time hire date (MM/DD/YYYY) Income reported by Hours working per week m W2 m 1099 m Other Anthem PCP name* Anthem PCP address* Anthem PCP ID no.* New patient?* A-77 LG-ASO Rev. 12/10 Page 2 of 5

3 Policyholder name Policyholder social security no. Section 5. FAMILY INFORMATION Spouse and dependents to be enrolled. Attach a separate sheet if necessary. Please read the Genetic Information Non-discrimination Act (GINA) information under Significant Terms, Conditions and Authorizations section, prior to answering questions below. 1 Relationship to employee: m Spouse m Domestic Partner (DP) Dependent name (last name, first name, M.I.) Social security no. (required for spouse or DP) Sex Date of birth Is dependent s address different than applicant s address? If yes, please provide full address m M m F Court ordered health care benefits? (If Yes, include legal documentation) Currently hospitalized or disabled? (If Yes, give reason) Anthem PCP name* Anthem PCP address* Anthem PCP ID no.* New patient?* 2 Relationship to employee: m Son m Daughter m Other Dependent name (last name, first name, M.I.) Social security no. Sex Date of birth Is dependent s address different than applicant s address? If yes, please provide full address m M m F Court ordered health care benefits? (If Yes, include legal documentation) Currently hospitalized or disabled? (If Yes, give reason) Anthem PCP name* Anthem PCP address* Anthem PCP ID no.* New patient?* 3 Relationship to employee: m Son m Daughter m Other Dependent name (last name, first name, M.I.) Social security no. Sex Date of birth Is dependent s address different than applicant s address? If yes, please provide full address m M m F Court ordered health care benefits? (If Yes, include legal documentation) Currently hospitalized or disabled? (If Yes, give reason) Anthem PCP name* Anthem PCP address* Anthem PCP ID no.* New patient?* Section 6. OTHER HEALTH COVERAGE Please check one: Yes (complete below) No On the day your coverage begins, list family members, including yourself, who will be covered by any other health coverage. Name of person(s) covered Relationship to employee Name of the HMO or insurance company Policy/certificate no. m Self m Spouse m Child(ren) Address of the HMO or insurance company Phone no. of HMO or insurance company Effective date (MM/DD/YYYY) Policyholder name Policyholder social security no. Policyholder date of birth Section 7. MEDICARE COVERAGE If you or your dependents are enrolled in Medicare or Medicaid, complete the following. 1 Name of enrollee (last name, first name, M.I.) Medicare Part A effective date Medicare Part B effective date Medicare/Medicaid ID no. ESRD onset date Medicare Part D ID no. Medicare Part D carrier Reason for Medicare entitlement Medicare Part D effective date Medicare Part D term date m Age m Disability m End stage renal disease (ESRD) m ESRD and disability 2 Name of enrollee (last name, first name, M.I.) Medicare Part A effective date Medicare Part B effective date Medicare/Medicaid ID no. ESRD onset date Medicare Part D ID no. Medicare Part D carrier Reason for Medicare entitlement Medicare Part D effective date Medicare Part D term date m Age m Disability m End stage renal disease (ESRD) m ESRD and disability *Only complete Primary Care Physician (PCP) information for HMO or POS products. A-77 LG-ASO Rev. 12/10 Page 3 of 5

4 Policyholder name Policyholder social security no. Section 8. PRIOR HEALTH COVERAGE. Please check one: Yes (complete below) No Have you been covered by Anthem within the past two (2) years? Group name/id no. Dates policy in effect Policy/Certificate no. Have you and/or your dependents had prior coverage with another carrier(s) in the past two (2) years? Section 9. SIGNIFICANT TERMS, CONDITIONS AND AUTHORIZATION (TERMS) Genetic Information Non-discrimination Act (GINA): When answering questions on this enrollment application, the information provided for each individual should include only information about that individual, and should not include any genetic information. Genetic information includes family medical history and information related to the individual s genetic testing, genetic services, genetic counseling, or genetic diseases for which the individual may be at risk. All responses pertaining to an individual will only be considered and applied to the individual in question. Health Savings Account Notice: Except as otherwise provided in any agreement between me and the financial custodian, the custodian of my Health Savings Account (HSA), I understand that my authorization is required before the financial custodian may provide Anthem Blue Cross and Blue Shield with information regarding my HSA. I hereby authorize the financial custodian to provide Anthem Blue Cross and Blue Shield with information about my HSA, including account number, account balance and information, regarding account activity. I also understand that I may provide Anthem Blue Cross and Blue Shield with a written request to revoke my authorization at any time. Please read this section carefully before signing the application. 1. I may not assign any payment under my Anthem Blue Cross and Blue Shield administered benefit plan. 2. I authorize deduction from my wages/pension, if necessary for the required payment for the benefit for which I, or any dependents have applied. 3. I am applying for the benefit selected on this application. If I select a coverage, or combination of coverages, not available to me and/or a class for which I am not eligible, I agree that my selection(s) is hereby automatically amended to be consistent with the employer s application. 4. I understand that, to the extent permitted by law, Anthem reserves the right to accept or decline this application and that no right whatsoever is created by this application. I also understand that this coverage, if approved, may exclude for pre-existing conditions. 5. I am responsible to timely notify my employer of any change that would make me or any dependent ineligible for benefits. 6. By signing this application, I agree and consent to the recording and/or monitoring of any telephone conversation between Anthem and myself. I acknowledge that I have read the Significant Terms, Conditions and Authorizations, and I accept such provisions as a condition of enrollment. I represent that the answers given to all questions on this application are true and accurate to the best of my knowledge and I understand they are being relied on by Anthem in accepting this application. I understand that any misstatements or failure to report new medical information prior to my effective date may result in a material change to benefits or rates. Any material misrepresentation or significant omission found in this application may result to denial of benefits or rescission or cancellation of my benefits. Ohio: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud. Kentucky: Any person who knowingly and with intent to defraud any insurance company, health maintenance organization, self-insured plan, or other person, files an application for insurance or other form of health care coverage 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. I give this authorization for and on behalf of any eligible dependents and myself if covered by the Plan. I am acting as their agent and representative. Your health benefit plan will be administered by one of the following companies based upon the state in which your employer is located: In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. In Missouri: Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. In WIsconsin: Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ( BCBSWi ), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ( Compcare ), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Thank you for choosing Anthem Blue Cross and Blue Shield. List prior carrier(s) Dates policy in effect Please check the type of prior coverage: m Employee only m Employee and spouse m Employee and child(ren) m Employee/spouse/child(ren) Termination reason: m Divorce/legal separation m Death of spouse m COBRA coverage exhausted m Group plan terminated m Employer/group contribution ceased m Employment terminated m Other Read the TERMS section above carefully before signing. Please review your application for errors or omissions. By signing this, I am indicating that I have read and understand the language in the TERMS section of this application and agree to all of its terms. Applicant signature X A-77 LG-ASO Rev. 12/10 Date Page 4 of 5

5 Policyholder name Policyholder social security no. Section 10. WAIVER OF COVERAGE For employee and/or any eligible dependent not enrolling. Check all that apply: Waiving: m Health m Dental m Vision m Life m All Name of person waiving Already protected by coverage of: m Spouse m Parent m None Employer name Carrier: m Anthem (give certificate/policy no.) m Other carrier (give name, ID no.) Check all that apply: Waiving: m Health m Dental m Vision m Life m All Name of person waiving Already protected by coverage of: m Spouse m Parent m None Employer name Carrier: m Anthem (give certificate/policy no.) m Other carrier (give name, ID no.) Check all that apply: Waiving: m Health m Dental m Vision m Life m All Name of person waiving Already protected by coverage of: m Spouse m Parent m None Employer name Carrier: m Anthem (give certificate/policy no.) m Other carrier (give name, ID no.) Check all that apply: Waiving: m Health m Dental m Vision m Life m All Name of person waiving Already protected by coverage of: m Spouse m Parent m None Employer name Carrier: m Anthem (give certificate/policy no.) m Other carrier (give name, ID no.) Check all that apply: Waiving: m Health m Dental m Vision m Life m All Name of person waiving Already protected by coverage of: m Spouse m Parent m None Employer name Carrier: m Anthem (give certificate/policy no.) m Other carrier (give name, ID no.) I certify that I have been given an opportunity to apply for the employer s health benefits plan, and after careful consideration, have decided not to take advantage of this offer. In the event I wish to apply for such benefits hereafter, I may do so, subject to established procedures. If I am declining enrollment for myself or my dependents (including my spouse) because of other health insurance coverage, I may in the future be able to enroll myself or my dependents in this plan, provided that enrollment is requested within 31 days after other coverage ends. My dependent(s) or I may be subject to pre-existing condition restrictions or waiting periods specified in the group benefit booklet, if a dependent or I are late enrollees. The pre-existing exclusion may not apply to a dependent who is enrolled in the plan prior to his/her 19 th Birthday. In addition, if I have a dependent as a result of marriage, birth, adoption or placement for adoption. I may be able to enroll myself and my dependents provided that I request enrollment within 31 days after the marriage, birth, adoption or placement of adoption. I also understand that my dependents and I may enroll under two additional circumstances: }} Either my or my dependent s Medicaid or Children s Health Insurance Program (CHIP) coverage is terminated as a result of loss of eligibility; or }} My dependent or I become eligible for a subsidy (state premium assistance program). In these cases, I may be able to enroll myself and my dependents provided that I request enrollment within 60 days of the loss of Medicaid/CHIP or of the eligibility determination. Applicant signature X A-77 LG-ASO Rev. 12/10 Date Page 5 of 5

6 Please include a copy of the applicable forms with the completed insurance enrollment form: - Copy of marriage certificate if married and seek to cover your spouse under your insurance - Copy of the birth certificate of any dependent if you seek to cover them under your insurance If you have any questions please contact Human Resources at

7 2015 Plan Year TOBACCO AFFIDAVIT FOR VU EMPLOYEES AND RETIREES Please mail the completed form to Human Resources, 1002 North First Street or fax to A Tobacco Affidavit must be completed annually by employees to avoid a $35 biweekly tobacco-user surcharge. The employee can also certify the non-use of tobacco for a spouse. Individuals are considered a tobacco user if they use any form of tobacco products that are smoked (e.g., cigarettes, cigars, pipes), applied to the gums (e.g., dipping, chewing tobacco, or snuff) and/or inhaled. After the open enrollment period, the employee/spouse who is not tobacco free may participate in a tobacco cessation program. The surcharge will be waived upon successful completion of the program (the employee/spouse becomes tobacco-free). TOBACCO AFFIDAVIT By checking below, I affirm I have read and understand the information in this affidavit. I am making this affirmation in order to waive the 2015 tobacco-surcharge. I understand that if I, or my spouse, begin routine tobacco use during the year, I am required to report this change to Human Resources immediately and will be charged the tobacco-user surcharge. I understand that tobacco includes any form of tobacco products that are smoked (e.g., cigarettes, cigars, pipes), applied to the gums (e.g., dipping, chewing tobacco, or snuff), and/or inhaled. I understand that the intentional falsification of this affidavit or failure to report the commencement of tobacco use after completing this affidavit could lead to loss of my health care coverage. Employee: I do not use tobacco products and agree not to use any tobacco products during the 2015 plan year. I use tobacco products. Spouse: I do not use tobacco products and agree not to use any tobacco products during the 2015 plan year. I use tobacco products. Employee s Name (Printed): Employee A# or Social Security: Employee s Signature: Date:

8 INSURANCE APPLICATION Life Insurance Company of North America (LINA) a Cigna Company (herein called the Insurance Company) For info and customer service call The applicant must sign and date this form. This form cannot be considered unless received within 30 days of the date it is dated. Important: Please enter all dates in mm/dd/yyyy format. EMPLOYER USE (MANDATORY DATA NEEDED): In order to process this application, the employer must complete this information. EMPLOYER Vincennes University CLASS LOCATION/PAYCODE# DATE OF HIRE ANNUAL SALARY VERIFIED BY REASON FOR REQUEST: NEW HIRE INITIAL ENROLLMENT EVENT ONGOING ENROLLMENT EVENT LATE ENTRANT NEW COVERAGE (TOTAL) CURRENT COVERAGE GUARANTEED COVERAGE PORTION OF REQUESTED INCREASE AMOUNT SUBJECT TOMEDICAL EVIDENCE Please print (preferably in black ink). EMPLOYEE SECTION VOLUNTARY EMPLOYEE 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 your election exceeds the Guaranteed Coverage Amount, or 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) above the Guaranteed Coverage Amount. TERM LIFE INSURANCE POLICY NO. FLX Voluntary Employee-Paid Coverage Applicant Employee Decline Requested Amount 1 times salary Guaranteed Coverage Amount* $150,000 *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. BENEFICIARY To specify a beneficiary, complete the section below. 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. Insured Beneficiary Percentage Social Security # Date of Birth Relationship Employee (Life) 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. Please Sign Here TL Signature Important: You must also sign and date the Agreements and Authorization section. Return application to your employer. Be sure to make a copy for your own records. Date

9 Applicant s Name Social Security # IMPORTANT Please complete each section that follows if it is needed. Read the Agreements and Authorization. Sign and date the form in the space provided. Complete the employee information in this section if you (i.e., the Employee) are applying for Life Insurance that is greater than the guaranteed amount or are applying for Life Insurance more than 31 days after you were eligible for the insurance. Employee Height ft in Weight Employee Physician Name lbs Height and Weight Information PHYSICIAN SECTION Phone No. Street Address City State Zip Please indicate your answers for each question by checking the Yes or No box for the question. SECTION A Within the last 5 years has the proposed insured been: diagnosed with any of the conditions shown in items A through J below, told by a medical professional he/she has or may have any of the conditions shown in items A through J below, or been treated by a medical professional for any of the conditions shown in items A through J below? Employee Yes No A. High blood pressure, heart attack, chest pain or Angina, a heart murmur, poor circulation or any other condition affecting the heart or circulatory system? B. Diabetes, glandular condition, Hepatitis, or any condition affecting the esophagus, stomach, intestines, liver or pancreas? C. Asthma, Chronic Bronchitis, Emphysema, or any other condition affecting the lungs or respiratory tract? D. Any condition affecting the kidneys, urinary tract, prostate gland or reproductive system? E. HIV infection, AIDS, or any other condition affecting the immune system or lymph nodes? F. Stroke, Transient Ischemic Attack (TIA), Alzheimer s disease, paralysis, Epilepsy, fainting, seizures, headaches, or other condition affecting the nervous system? G. Anemia or any other condition affecting the blood, Lupus, Arthritis, deformity or loss of limb? H. Anxiety, Depression, Bipolar Disorder, or any other mental disorder or condition? I. Cancer, Tumor, Leukemia, Hodgkin s Disease, Polyps or Mole? J. Alcohol or drug abuse or dependency? SECTION B Within the last 5 years has the proposed insured: A. Had a Driving While Intoxicated (DWI), Driving Under the Influence (DUI) or Operating Under the Influence (OUI) conviction? B. Smoked cigarettes: 1. For how many years has the proposed insured smoked? 2. Approximately how many cigarettes are, or were, smoked on average per day? C. 3. If cigarette smoking has been discontinued, when (month and year) did the proposed insured quit smoking? Used any controlled or illegal drug or other substance? D. Been seen for, or been advised to have sought treatment for, observation and/or consultation for surgery, medical examination, and/or tests, such as blood, urine, X-rays, electrocardiograms, scans, biopsies, or any medical tests/exams not listed here or above, other than normal routine physical exams? E. Used any medication prescribed by a physician or other medical practitioner, or used any form of alternative and complementary medical treatment or remedy, including herbs or acupuncture? F. Been seen, sought treatment for, consulted, advised they had and/or received any medical advice from a health care practitioner for any disease, disorder and/or medical impairment not listed above? Use the space below to explain "Yes" answers. If more space is needed, use a new page. Sign and date it. Attach it to this form. Name of Employee Medical Condition Date Occurred Duration/Treatment Received Current Status Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. Important: You must also sign and date the Agreements and Authorization section. Fold and staple this page to conceal health questions. Return application to your employer. Be sure to make a copy for your own records. TL

10 Applicant s Name Social Security # AGREEMENTS AND AUTHORIZATION To the best of my knowledge and belief all written, telephonic and electronic info I gave is true and complete. I understand that my insurance will not go into effect unless I am actively at work on the effective date. The conditions for the requested insurance to be effective are described in the policy and certificate. The approval of this request by the Insurance Company is one of those conditions. I understand and agree that: (1) This request will be a part of the policy that provides the insurance. (2) I may need to provide more medical info. (3) I may need to take medical tests and report the results to the Insurance Company. (4) I must report any change in my health that happens before the insurance is effective. (5) Requested insurance will not be effective for a person if the person does not meet the underwriting requirements on the date insurance is to be effective. Authorization. I permit any hospital, clinic, health care practitioner, pharmacy, benefit manager, employer, insurance company, the Medical Information Bureau (MIB) or any other person or organization having info about my health, medical history, physical or mental condition, diagnosis or treatment, employment or income, or motor vehicle driving record, to disclose to the Insurance Company or its authorized agent, any such info, for the purpose of underwriting this application for insurance or administering any claim under any insurance which is approved. This authorization is valid for 30 months from the date below. I accept that a copy of this Authorization is as valid as the original. I understand that I and/or my authorized agent have the right to receive a copy of this authorization upon request. I understand that the info will be used to assess my request for insurance. I may revoke this authorization at any time in writing. Any such revocation will not: (1) change any action taken in reliance on the Authorization; and (2) change the Insurance Company s right to use the Authorization for contest of a claim or policy in accordance with applicable law. I understand that info provided pursuant to this authorization may be disclosed by the recipient and is no longer subject to the protections of the Health Insurance Portability and Accountability Act (HIPAA). (The Insurance Companies are subject to the Gramm-Leach-Bliley act and state privacy laws. They do not disclose protected information except as permitted by those laws.) Sign Here Employee's Signature Month/Day/Year Notice: Personal information may be collected from persons other than those proposed for coverage. Information may be disclosed to third parties without your authorization as permitted by law. You have the right to access and correct all personal information collected. Additional information about the insurance company s privacy practices is available upon request. TL

11 LIFE INSURANCE COMPANY OF NORTH AMERICA POLICYHOLDER POLICY NUMBER VINCENNES UNIVERSITY LK Long-Term Disability (LTD) Enrollment Form Name Sex: Male Female Last First M. I. Date of Birth Social Security No. / / - / - / / / Address Home Phone ( ) Number and Street City State Zip Code Date Hired Title or Occupation Annual Salary $ Please check the appropriate box. I accept the LTD insurance provided by the Company s Group Insurance Plan and authorize the deduction from my earnings of the required contribution toward the cost of the insurance. I have been offered LTD insurance and decline to purchase it at this time. 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. Late entrants must complete an Evidence of Insurability Form. Coverage for late entrants is subject to the Insurance Company s approval. If you are not in active service on the date your coverage would otherwise take effect, you will be covered on the date you return to active service. Pre-Existing Condition Limitation: A pre-existing condition is any injury or illness for which you have consulted a physician (or for which a reasonable person would have consulted a physician), received medical treatment, care or services (including diagnostic measures), taken prescribed drugs or medicines, or incurred expenses during the 3 months prior to the effective date of your insurance. If you become disabled due to a pre-existing condition, you will not receive benefits unless your disability begins more than 12 months after the effective date of your coverage. Signature of Applicant Date TL (BME) Return original to your employer and make a copy for your records.