AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224

Transcription

1 AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA Remarks: ENROLLMENT FORM c New Certificate c Change/Increase Certificate # This box for AHL Home Office use only GENERAL INFORMATION Employee s/payor s/owner s (Certificateholder) Name (Last, First, M.I.) Residence Address City c M c F Social Security Number State Zip Date of Birth Phone Number Employer/Association/Union Date Hired Occupation Plant Or Division Primary Beneficiary s Full Name and Address City State Zip Relationship Phone Number Date of Birth Contingent Beneficiary s Full Name and Address City Social Security Number State Zip Relationship Phone Number Date of Birth Social Security Number Last Name COMPLETE THIS SECTION FOR PERSONS TO BE INSURED First Name Relationship Sex Date of Birth Social Security Number Employee Spouse Tobacco Use* (Life or Critical Illness) ** ** *Has any adult (19 and older) person to be insured used tobacco in the last 12 months? (**If applying for Life or Critical Illness.) Are you applying for coverage or changing existing coverage due to a qualifying event? Accident Disability (STD) Cancer/Specified Disease Hospital Indemnity Critical Illness Term Life Dental Universal Life If Yes, check the qualifying event: c Marriage c Divorce c Birth/Adoption c Spouse/Dependent Child Death c Eligible/Ineligible Child c Spouse New Job/Job Loss c Newly Eligible c Termination c Employee Death Date of Qualifying Event Current Certificate Number(s) Do you currently have any of the following Individual coverages with American Heritage Life Insurance Company (AHL)? Accident Cancer Critical Illness Disability Hospital Indemnity If you answered Yes to any of the coverages, please enter the Policy Number Do you wish to terminate this coverage? If Yes, please enter effective date of termination ABJ4580FL5 Page 1 of 6

2 ENROLLMENT FORM /Billing Mode c Monthly c Semi-monthly c Bi-weekly c Weekly c Other Date of First Deduction Coverage Effective Date Account Number Employee ID Situs State Accident (GVAP6) On and Off the Job Accident Off the Job Accident c Accident Treatment & Urgent Care Rider c Emergency Room Services Rider c Outpatient Physician s Rider Base SELECTION OF COVERAGE (Answer Yes or No and complete for each coverage selected) c Dislocation/Fracture Rider c Benefit Enhancement Rider c Accidental Death, Dismemberment and Functional Loss Rider Accident (GVAP1) (On and Off the Job Accident) Base c Benefit Enhancement Rider Optional Disability Riders for Employee c Off the Job Accident c Off the Job Accident and Sickness c On and Off the Job Accident c On and Off the Job Accident and Sickness Employee Monthly Salary Rider Cancer/Specified Disease (GVCP2) Benefits Plan Hospital Radiation / Chemotherapy Surgery Related Misc. 1 c Cancer Initial Diagnosis Option c Intensive Care Option c Cancer Screening Option Critical Illness (GVCIP2) Basic Benefit Amount c Supplemental Critical Illness Option II c Wellness Option c 2 nd Event Cancer Critical Illness Option c Cancer Critical Illness Option c 2 nd Event Initial Critical Illness Option c Supplemental Critical Illness Option I (HIV) c Chronic Illness Critical Illness Rider c 90 days c 365 days Critical Illness (GVCIP1) (My Lifeline) Basic Benefit Amount If covered, Basic Benefit Amount for spouse or other dependents is 50 of the employee s. c Critical Illness Cancer Option ABJ4580FL5 Page 2 of 6 c Recurrence Option c Wellness Option

3 Disability (Short-Term) (GVDIP) Monthly Salary Monthly Benefit (My Lifeline) Elimination Period Days Acc. Days Sick. ENROLLMENT FORM SELECTION OF COVERAGE (Answer Yes or No and complete for each coverage selected) A. Is this insurance to replace any existing disability coverage? Benefit Period Months If yes, provide the Company Name B. Is there any other disability insurance in force or applied for that will continue after the effective date of this coverage? If yes, complete the following: Company Name Year Issued Monthly Benefit Elimination Period Benefit Period Hospital Indemnity (GVSP1) Benefits Hospital Related Surgery / Inpatient Physician Outpatient Related c Diagnostic / Wellness Option c Prescription Drug Option c Disability Rider 1 c Life Rider Heritage Choice Dental c Plan 1 c Plan 4 c Plan 2 c Plan 5 c Plan 3 c Employee +One Child Were you covered under your Employer s prior Dental Plan? If Yes, please enter the date coverage effective ABJ4580FL5 Page 3 of 6

4 Life SELECTION OF COVERAGE (Answer Yes or No and complete for each coverage selected) Abbreviations: GI - Guaranteed Issue c Universal Life (UL) c Term Life cx GI (Employee only) ENROLLMENT FORM Face Amount Death Benefit Option c 1 c 2 (UL ONLY) Employee s Annual Salary Life Riders Rider Rider Rider Rider Rider Rider Rider Rider /Amt Replacement and Existing Insurance Section (Must Answer) 1a. Replacement. Proposed Insured. Is this insurance to replace or change any existing life coverage? If yes, indicate product being replaced or changed and complete replacement form provided by your agent (producer), if required by your state. 1b. Agent (Producer). To your knowledge, is change or replacement involved? 2a. Existing Insurance. Proposed Insured. Is there any other (not listed in Question 1a.) life insurance in force or applied for on the proposed insured? If yes, list company name, policy number, year issued, type of coverage, and amount of benefit. 2b. Agent (Producer). To your knowledge, does the proposed insured have existing coverage in force? Illustration Regulation Certification 3a. Illustration Certification. Owner. The owner certifies that no illustration conforming to the coverage applied for was provided, but that an illustration conforming to the coverage issued will be provided upon delivery of the certificate. If no, complete the applicable illustration certification form provided, if required in your state. 3b. Agent (Producer). The Agent (Producer) certifies that no illustration conforming to the coverage applied for was provided, but that an illustration conforming to the coverage issued will be provided upon delivery of the certificate. If no, complete the applicable illustration certification form provided, if required in your state. ABJ4580FL5 Page 4 of 6

5 ENROLLMENT FORM SELECTION OF COVERAGE (Answer Yes or No and complete for each coverage selected) Long Term Care Insurance Accelerated Death Benefit Rider (Must Answer) Employee Questions 4. Secondary Addressee Designation. Would you like to designate at least one additional person to receive notification of a possible lapse or termination of coverage? If yes, please provide full name and mailing address. Please inform us of any change made to the address of the secondary addressee. If no, see below waiver. Name (Last, First, MI) Street City State Zip Waiver: Protection against unintended lapse - I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long term care insurance rider for nonpayment of premium. I understand that notice will not be given until 30 days after a premium is due and unpaid. I elect NOT to designate any person to receive such notice. 5. Replacement. Do you intend to replace any other accident and sickness or long term care policy or certificate presently in force with this rider? If yes, please indicate product being replaced or changed and complete replacement form provided by your agent (producer), if required by your state. 6a. Existing Insurance. Do you have another long term care insurance policy, certificate or rider in force (including health care service contract or health maintenance organization contract)? 6b. Did you have another long term care insurance policy, certificate or rider in force during the last 12 months? If so, with which company? If that insurance lapsed, when did it lapse? 6c. Are you covered by Medicaid? 7a. Agent (Producer). List all health insurance policies which you have sold the applicant. 7b. Agent (Producer). List all health insurance policies you sold to this applicant which are still in force. 7c. Agent (Producer). List all health insurance policies you sold to this applicant in the past five years that are no longer in force. Disability & Life Eligibility Question Is the employee actively at work now, for wage or profit, and has he/she worked at least 20 hours each week performing all duties of his/her regular occupation at his/her regular place of employment for at least the last 3 months except for minor illness or injury of 1 week or less, or normal pregnancy? EMPLOYEE ABJ4580FL5 Page 5 of 6

6 ACCEPTANCE/AUTHORIZATION: I hereby request all coverage(s) checked yes above for which I am or may become eligible under the group coverages issued by AHL. I AUTHORIZE my employer to deduct from my salary or wages, if applicable, the necessary premium for the coverages requested. EFFECTIVE DATE: I understand that the effective date of my elected coverages will be the effective date recorded on my Certificate, not the date this Enrollment form is signed. WAIVER/DECLINATION: I understand that if I refuse any coverage for which I am eligible (by checking no above), 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. FRAUD NOTICE: 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. Date Signed Employee s Signature Agent s (Producer s) Statement. I certify that to the best of my knowledge and belief the information on this form is complete, accurate and correctly recorded. Signature of Soliciting Florida Agent (Producer) Print Soliciting Agent (Producer) Name Florida Agent License Number To be completed by home office or agent (producer), prior to issue: Agent (Producer) Name Agent (Producer) Number Servicing Agent (Producer): Soliciting Agent (Producer): National Agent (Producer) Number (NPN) Percentage Credit ABJ4580FL5 Page 6 of 6

7 AMERICAN HERITAGE LIFE INSURANCE COMPANY HOME OFFICE: 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA (904) A Stock Company IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when it pays: Hospital or medical expenses up to the maximum stated in the policy Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: Hospitalization Physician services Outpatient prescription drugs if you are enrolled in Medicare Part D Other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIIP). AWD (AWDPKG1)

8 AMERICAN HERITAGE LIFE INSURANCE COMPANY HOME OFFICE: 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA (904) A Stock Company IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when it pays: hospital or medical expenses up to the maximum stated in the policy Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice outpatient prescription drugs if you are enrolled in Medicare Part D other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIIP). AWD3431-1

9 AMERICAN HERITAGE LIFE INSURANCE COMPANY HOME OFFICE: 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA (904) A Stock Company IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when: any expenses or services covered by the policy are also covered by Medicare Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice outpatient prescription drugs if you are enrolled in Medicare Part D other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIIP). AWD6301-1