PROVIDENT LIFE and ACCIDENT INSURANCE COMPANY 1 Fountain Square Chattanooga, TN 37402 APPLICATION FOR VOLUNTARY SPECIFIED CRITICAL ILLNESS INSURANCE New Policy Additional Policy Internal Policy Replacement Change to Existing Policy Please Print Section A: EMPLOYEE Information - Always complete. 1. Name (First) (Middle) (Last) 2. Social Security No. 3. Residence Address (Street/Box No.) (City) (State) (Zip) 4. Birthdate 5. Age 6. Sex F M 7. Home Phone Number 8. Employer s Name 9. Employment Date 10. Are you actively at work? 11. Employee/Payroll No. 12. Occupation 13. Scheduled Number of Work Hours per Week 14. Primary Beneficiary/Relationship 15. Contingent Beneficiary/Relationship Section B: SPOUSE Information - Complete ONLY if applying for Rider. 16. Name (First) (Middle) (Last) 17. Birthdate 18. Age 19. Sex F M 20. Occupation 21. Primary Beneficiary/Relationship 22. Contingent Beneficiary/Relationship L-21789-MD Page 1 of 4 (10/08)
Section C: COVERAGE Information Complete questions 23 and 24 for Employee Policy and for Spouse Rider. Employee 23. Have you used any tobacco products (cigarettes, cigars, snuff/dip/chew, pipe) and/or any nicotine delivery systems within the last 12 months?... 24. Will coverage applied for replace or modify any existing health insurance?.. If "Yes", give company name and submit required replacement forms if needed. Employee Spouse Rider 25. Specified Critical Illness Benefit Amount $ $ $ Yes Yes Child Rider Additional Specified Critical Illness Benefit Premium Amount $ $ $ $ Health Screening Benefit Rider $ $ $ $ No No Spouse Premium Other $ $ $ $ Other $ $ $ $ Payroll Premium Deducted: Weekly Bi-weekly Semi-monthly Monthly Other Total $ TOTAL PAYROLL PREMIUM: $ SECTION D: MODIFIED ISSUE - Employee, Spouse Rider, and/or Child Rider. Complete question 28 only if applying for the Additional Specified Critical Illness Benefit. In the past 7 years, have you: Employee Spouse Rider Child Rider ($10,000) 26. Been diagnosed with or sought medical treatment (including medication) for: heart attack, coronary disease or surgery, stroke or transient ischemic attack, organ transplant, renal (kidney) disease or failure, hepatitis B or C, cirrhosis, emphysema, chronic obstructive pulmonary disorder or diabetes (excluding gestational diabetes)?... 27. Been prescribed three or more medications to be taken concurrently for high blood pressure?... 28. Been diagnosed with or sought medical treatment (including medication) for: cancer including Leukemia, Hodgkin's Disease, skin cancer (excluding basal cell cancer) or malignant tumors of any kind?... L-21789-MD Page 2 of 4 (10/08)
SECTION E: SIMPLIFIED ISSUE - Employee Policy Only Complete in addition to previous questions. If "Yes" to question 32 or 33, please provide details in section 34. 29. Height ft. in. 30. Weight lbs. 31. Within the past 7 years have you tested positive for HIV virus or its antibodies, or been diagnosed with or received treatment for acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC)?... 32. Within the past 7 years have you received medical advice or sought treatment for: liver disorder including cirrhosis or hepatitis (other than type A), any heart, circulatory, lung, respiratory or kidney disorder? If yes provide details in section 34.... 33. Within the past 5 years, have you received medical advice or sought treatment for any disease or disorder or had surgery (other than for broken bones or lacerations) not previously disclosed during this application process? If yes provide details in section 34.... 34. Condition Medication Date of Onset Doctor's/Hospital's Name and Address Type of Treatment Date of Recovery L-21789-MD Page 3 of 4 (10/08)
EMPLOYEE (PRIMARY INSURED) STATEMENTS I understand that coverage issued is based on all statements and answers recorded above. I agree that any child proposed for rider coverage must be dependent on me for at least 50% of his/her support to be covered for benefits. These statements and answers are complete and true to the best of my knowledge and belief. I understand that as the undersigned, I am the owner of any coverage issued under this application. I understand the Coverage Effective Date of insurance as shown in the Policy Schedule is subject to the application being acceptable under Provident s rules, limits and standards and the insurance is, or would have been issued as applied for (or if not issued as applied for, then as modified). The Coverage Effective Date will be no earlier than the application signed date and no later than the date payroll deductions begin or premiums are collected for non-payroll deducted policies. I authorize my employer to deduct the premiums for this insurance from my earnings (unless I have completed additional forms for a non-payroll method). Dated (Month/Day/Year) at (City, State) If this box is checked, a PIN # secured enrollment has authorized the application and a signature is not required. Employee Signature INSURANCE PRODUCER STATEMENTS: (1) Do you have knowledge or reason to believe that the proposed insurance is intended to replace any existing insurance or annuities? (2) To the best of your knowledge and belief, the above statements and answers are complete and true. Dated (Month/Day/Year) Licensed Insurance Producer's Signature Insurance Producer's License No. Printed Name of Insurance Producer For Home Office Use Only Policy Number: Employee L-21789-MD Page 4 of 4 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. (10/08)
(Applicant) (Applicant) INSTRUCTIONS Complete the information below only if you or any person proposed for coverage on the preceding application is currently eligible for Medicare. To be eligible for Medicare, you must be either: (1) age 65 or older; or (2) disabled. Medicare Certification Form This is to certify that I have received the "Guide to Health Insurance for People with Medicare" and the "Important Notice to Persons on Medicare". Date Signature of Applicant