Section 5 MEMBER SPOUSE In the last 2 years have you or your Spouse been unable to perform the full-time duties of your occupation for 10 consecutive

Similar documents
Spouse/Domestic Partner's Name: (First, Middle Initial, Last), if applying Spouse/Domestic Partner's Occupation: Basic Monthly Pay: $ Section 4 COVERA

THIS PAGE IS INTENTIONALLY LEFT BLANK. * *

Please answer these brief questions. Member Spouse 1. To the best of the applicant's/member's knowledge and belief, has the applicant/member or spouse

HOSPITAL INCOME AND SHORT TERM RECOVERY INSURANCE PLAN CONFIRMATION FORM

Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, been positively diagnosed or treated for: chest

Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated

Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever been diagnosed with, or been treated for:

GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM

Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated

THIS PAGE IS INTENTIONALLY LEFT BLANK. * *

GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM

Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated

Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated

Thank you for inquiring about the AFA Short Term Recovery Insurance Plan (RecoveryCare).

Medico Medicare Supplement Insurance

TERM LIFE INSURANCE PLAN ENROLLMENT FORM

Coverage to Help Meet Your Needs!

Please answer these brief questions. To the best of your knowledge and belief: 1. Have you ever been diagnosed with, or been treated for (Circle speci

Please answer these brief questions. To the best of your knowledge and belief: 1. During the past 5 years, have you had or been treated for (Circle sp

THIS PAGE IS INTENTIONALLY LEFT BLANK. * *

The United States Life Insurance Company in the City of New York Please answer these brief questions. To the best of your knowledge and belief: 1. Hav

Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with you

Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with you

Coverage to Help Meet Your Needs!

3. Please read, sign and date: To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever receive

3. Please read, sign and date: To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever receive

VOLUNTARY GROUP TERM LIFE INSURANCE:

Medico Dental Plus Insurance Series

3. Please read, sign and date: To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever receive

3. Please read, sign and date: To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever receive

Dental, Vision & Hearing

THIS PAGE IS INTENTIONALLY LEFT BLANK. * *

Group Policy G SOCIAL SECURITY NO. WEIGHT LBS. BILLING ADDRESS / / CITY STATE ZIP CODE HOME PHONE

Standard Insurance Company. Individual Client Services PO Box 711 Portland OR Policy Change Form and Application Supplement A

GROUP CATASTROPHE MAJOR MEDICAL PLAN

3. Please read, sign and date: To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever receive

Agent Instruction for Submitting New Application

I understand that the insurance applied for will take effect on the date specified by The United States Life Insurance Company in the City of New York

Last name First name MI. Apt / Suite / PO box number Gender m Female m Male Language of choice m English m Spanish City State Zip code County / Parish

Application for Alumni Insurance

Medicare Select Enrollment Application

LTD EMPLOYER'S STATEMENT

Continuum Application Statement of Health Form for Health Care and Dental Care Insurance

Application Enrollment Form for AVMA LIFE Trust Group Insurance Program

Anthem Blue Cross and Blue Shield Medicare Supplement Application Maine

RETURN THIS COPY TO JOHN HANCOCK. City/Town: State: Zip:

Confinement Waiver Instructions

Please send your completed form to: Claims Department P.O. Box Atlanta, Georgia 30342

NATIONAL SLOVAK SOCIETY OF THE UNITED STATES OF AMERICA

For faster claim payment* please submit your claim online at

They grow up fast. Protect them while you can.

* *

Accident and Sickness

The Prudential Insurance Company of America

MoDOT & Patrol Employees Retirement System MPERS Disability Benefits Claim Packet Instructions

Sun Life Assurance Company of Canada

RATE AND BILLING OPTIONS - Please check one: Please select the type of coverage you would like. Enclose a check for the rate selected and mail it with

The Prudential Insurance Company of America

CLAIM FORM. DATE OF BIRTH: 3. PATIENT'S NAME & ADDRESS- IF ADDRESS IS NEW, PLEASE CHECK BOX r PHONE: ( )

RATE AND BILLING OPTIONS - Please check one: Please select the type of coverage you would like. Enclose a check for the rate selected and mail it with

To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever received treatment or been medically a

If you do not have access to a fax machine, send the completed application and any additional documents to:

INDIVIDUAL PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR MISCELLANEOUS ALLIED HEALTH PROFESSIONALS

Application For Compassionate Assistance Loan Claimant's Statement

RATE AND BILLING OPTIONS Indicate how you wish to be billed: G Member Only Coverage G Family Coverage G Automatic Monthly Check Withdrawal G Member +1

To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever received treatment or been medically a

Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male

EDUCATORS PROFESSIONAL LIABILITY INSURANCE PLAN APPLICATION CLAIMS-MADE PROFESSIONAL LIABILITY Underwritten By: Liberty Insurance Underwriters Inc.

ACCIDENTAL DEATH WHOLE LIFE PROTECTOR

Humana Insurance Company Hospital Indemnity Claim Filing Instructions

IMPORTANT: To enroll in this benefit for Retired Reservists, simply complete and sign the enclosed Enrollment Form.

Application for Reinstatement United Home Life Insurance Company 225 S. East St. P.O. Box 7192 Indianapolis, IN

Medico Dental Insurance Portfolio

Group Term Life Application for 10-Year or 20-Year Level Term Rate

Voluntary Disability Benefits

As a Retired Reservist or Shipmate you may have recently become eligible to purchase the TRICARE Retired Reserve Supplement Insurance coverage.

Short Term Disability Income Benefits. Great-West G R O U P. Employee s Statement

Endorsed by: American Anthropological Association CANCER INSURANCE PLAN APPLICATION Residents of CA, KS and WI: Please contact Administrator for a spe

Group Customer #

VISITORS TO CANADA Insurance Claim Form

Great-West G R O U P. Long Term Disability Income Benefits. Employee s Statement

PERSONAL HEALTH APPLICATION

RESIDENCE ADDRESS. Council Location (City & State) MODAL PREMIUM: PART I HEALTH QUESTIONS

IEEE BENEFIT ENROLLMENT FORM IEEE Group Accidental Death & Dismemberment Insurance Plan

Missouri Individual Enrollment Application

Humana Employee Enrollment Application Employees

Short Term Disability Income Benefit. Employee s Guide

DO NOT USE THIS CLAIM KIT TO REPORT INJURIES INCURRED BY LOCAL CHURCH OR SCHOOL EMPLOYEES.

Office of the Administrator P.O. Box Des Moines, IA

THIS MEMBER BENEFIT OPPORTUNITY, TRICARE SUPPLEMENT INSURANCE PLAN (RESERVECARE), IS RESERVED FOR RESERVE OFFICER PERSONNEL ONLY

The Manufacturers Life Insurance Company WSE

Medico Dental Insurance Portfolio

THE PRESIDENT AND TRUSTEES OF WILLIAMS COLLEGE DBA WILLIAMS COLLEGE

AAA BENEFIT ENROLLMENT FORM AAA Group Accidental Death & Dismemberment Insurance Plan Name: Add 1: Add 2: City, St., Zip: Last First MI After the firs

Request for Group Insurance From: New York Life Insurance Company 51 Madison Avenue New York, NY 10010

Hospital Indemnity Insurance

Sun Life Assurance Company of Canada

INSURED STATEMENT OF CLAIM

The Roman Catholic Church of the Diocese of Phoenix

Level Term Life Insurance Plan

Transcription:

HARTFORD LIFE INSURANCE COMPANY Hartford, Connecticut 06155 National Active and Retired Federal Employees Association AGL-1545 Spouse's Name: (First, Middle Initial, Last), if applying Section 4 Amount Desired: ($5,000 to $20,000 in multiples of $5,000) Member: G $20,000 G $10,000 G $5,000 Spouse: G $20,000 G $10,000 G $5,000 The Spouse may not be covered under a Plan with benefits greater than 100% of the Member's Plan. Please indicate if request is for: G New Coverage G Change in Coverage Member's Current benefit amount: $ Additional benefit requested: $ Total benefit: $ Spouse's Current benefit amount: $ Additional benefit requested: $ Total benefit: $ IF REQUEST IS TO CHANGE EXISTING COVERAGE PRINT ONLY ADDITIONAL AMOUNT DESIRED LI648E-1545NY 29889/29893/ 1018/52247 0000001-0000001-0000181

Section 5 MEMBER SPOUSE In the last 2 years have you or your Spouse been unable to perform the full-time duties of your occupation for 10 consecutive days, or if not employed, been unable to carry out the normal and customary duties of a person of like age and sex in good health during the 90 day period immediately preceding the date of this application for 10 consecutive days? In the past 10 years, have you been diagnosed or treated by a member of the medical profession for: During the past 5 years, have you consulted any physician, surgeon, psychologist, psychiatrist or other practitioner for any reason not previously noted on this application; or been confined or treated in any hospital, sanatorium or similar institution? Section 6 The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Form PA-9356 (HL) (NY) 2 LI648E-1545NY *00000001000* 0000002-0000001-0000181

Section 7 Please read carefully all items and sign below. AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE INFORMATION I/We hereby certify that I/we have read all statements and answers in this application, and in any other application or medical form required by Hartford Life Insurance Company, and that they are full, complete, and true to the best of my/our knowledge and belief. I/We understand that any material misrepresentations in this application could cause a claim to be denied under any insurance issued based on this application. I/We also agree that a copy of this application shall be attached to and form a part of any certificate issued. I/we also understand that the Company may request whatever additional evidence of insurability it needs. Subject to the deferred effective date provision, I/we understand that coverage will not become effective until the Company grants its underwriting approval. I/We do not receive temporary or conditional insurance coverage just because I/we submit an application and paid my first premium. I/We authorize any: doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or reinsurer; Medical Information Bureau, Inc.; or employer; to give Hartford Life Insurance Company or its legal representative information about my/our or my/our dependent's physical or mental health, (including history, condition, diagnosis and treatment), drug or alcohol use history, other insurance coverage or employment status except drug and alcohol treatment information. Hartford Life Insurance Company will use the above information to decide if and to what extent I/we are eligible for insurance coverage or benefits under the Policy. This information will be treated as confidential. I/We understand the Medical Information Bureau, Inc. will release records or information only to Hartford Life Insurance Company. I/We authorize Hartford Life Insurance Company to give information about me/us to any other insurance company to whom I/we may apply for Life or Health Insurance, or other persons or organizations handling a claim, underwriting coverage applied for or administering coverage issued as a result of this application or as required by law. I/We authorize Hartford Life Insurance Company, or its reinsurers, to make a brief report of my/our personal health information to Medical Information Bureau. I/We understand that upon written request I/we may revoke this authorization except to the extent that action has already been taken in reliance on the authorization. This authorization expires two (2) years from the effective date of my/our coverage or my/our dependent's coverage or, if no coverage has been issued one (1) year from the date of this application. I/We understand that a photocopy of this form is as valid as the original, and that I/we have a right to receive a copy of this form upon request. I/We certify that I/we have received the Notice of Insurance Information Practices. I/We agree that this document and all of its contents shall form a part of my/our enrollment request for group benefits. Section 8 Proposed Insured's signature (Sign name in full) Required Date Required Spouse's signature (if applying) Required Date Required Section 9 Please check "Yes" or "No" on the next line. By applying for this insurance, do you intend to replace, discontinue, or change an existing policy of life insurance? You: G Yes G No Spouse: G Yes G No Form PA-9356 (HL) (NY) 3 LI648E-1545NY Indicate how you wish to be billed: G Automatic Monthly Check Withdrawal G Semi-Annual Direct Bill (If you select Automatic Check Withdrawal, please complete the Automatic Monthly Check Withdrawal Request.) TO APPLY: Send this completed form with your premium check payable to: ADMINISTRATOR NARFE GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? Call: 1-800-233-5764 E-Mail: NARFE.service@mercer.com 0000003-0000001-0000181

THIS PAGE IS INTENTIONALLY LEFT BLANK. *00010001000* 0000004-0000001-0000181

0000005-0000001-0000181

THIS PAGE IS INTENTIONALLY LEFT BLANK. *00020001000* 0000006-0000001-0000181

0000007-0000001-0000181

*00030001000* 0000008-0000001-0000181

0000009-0000001-0000181

THIS PAGE IS INTENTIONALLY LEFT BLANK. *00040001000* 0000010-0000001-0000181

For National Active and Retired Federal Employees Association Members 1 0000011-0000001-0000181

*00050001000* 2 0000012-0000001-0000181

3 0000013-0000001-0000181

Underwritten By: Hartford Life Insurance Company Hartford, CT 06155 *The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life Insurance Company. Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 10374 Des Moines, IA 50306-8812 Sponsored By: Administered by: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 10374 Des Moines, IA 50306-8812 Questions? 1-800-233-5764 http://www.personal-plans.com/narfe AR Insurance License #100102691 CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC Copyright 2018 Mercer LLC. All rights reserved. *00060001000* 4 0000014-0000001-0000181

5 0000015-0000001-0000181

THIS PAGE IS INTENTIONALLY LEFT BLANK. *00070001000* 0000016-0000001-0000181

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback