NOTIFICATION FOR THE PROPOSED INSURED— Please read carefully and detach for your records.
Insurance Fraud Warning- 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 may be guilty of a crime and subject to fines and confinement in prison.
Notice of Insurance Information Practices - In the course of properly underwriting and administering your insurance coverage, we will rely heavily
on information provided by you. We may also seek information from others, such as medical professionals who have treated you. In some cases, we
may ask a consumer reporting agency to collect information and submit an investigative consumer report to us. You have the right to request to be
interviewed in connection with the preparation of that report. You may receive a copy of the report upon request.
You have the right to be told about, and to see and copy if you wish, items of personal information about you which appear in our files, including
information contained in investigative consumer reports. You also have the right to seek correction of information you believe to be inaccurate.
THE ABOVE IS A GENERAL DESCRIPTION OF OUR INFORMATION PRACTICES. IF YOU WOULD LIKE TO RECEIVE A MORE DETAILED
EXPLANATION OF THOSE PRACTICES, PLEASE SEND YOUR REQUEST TO THE CHIEF UNDERWRITER, P.O. Box 1650, Little Rock, AR
72203
USAble Life
Little Rock, Arkansas
P. O. Box 1650
Little Rock, AR 72203
Instructions: 1. For $5,000 Basic Life/AD&D ONLY – complete rows 1, 2, 3, 4, 5, 7, 8, 9 and sign as well as date the
form.
2. For $5,000 Basic Life/AD&D AND/OR
Supplemental Life/AD&D, Dependent Life – complete all areas.
3. Return Completed Form to Your School District Payroll Office.
New Applicant Benefit Change Name Change Beneficiary Change
APPLICANT INFORMATION
1. Employer (Agency /School District Name)
Group Number
AS004404-________
Product(s) Basic Life/AD&D
Supplemental Life/AD&D
Dependent Life
2. Employee Social Security #
Employee Last Name First Name Middle Initial Date of Birth
Mo Date Year
3. Home Address Street City State Zip
Birth State or Country
4. Sex Male
Female
Height
(ft.-in.)
Weight
(lbs)
Marital
Status
Date of Hire (Include Month/Day/Year)
Occupation
5. Home Phone #
Work Phone # Annual Salary
6. Spouse & Children Information – Complete if Applying for Dependent’s Coverage
Person Proposed for insurance
Show first, middle, last name
Social Security # Occupation
Date of Birth & Place
Height Weight
Marital
Status
Sex
Mo. Day Yr.
State or
Country
(spouse)
(child)
(child)
(child)
BASIC/SUPPLEMENTAL/DEPENDENT LIFE
Supplemental Employee Life and AD&D
Are you currently enrolled in one of the Arkansas Public School
Employees qualified health plans?
Yes No
Classification By Insurance Check
Basic Annual Earnings
Amount One
$10,000 or less $20,000
$10,001 - $15,000 $30,000
$15,001 - $20,000 $40,000
$20,001 - $25,000 $50,000
$25,001 - $30,000 $60,000
$30,001 and above $70,000
Dependent Life
Yes No
Spouse:
$2,500
Your spouse/child will not be
covered for Dep. Life if also
covered as an employee of the
AR Public School Group.
Child(ren):
$2,500 - 3 years of age and over
$1,000 - 14 days of age to 3
years of age
Monthly Premium
$5,000 Basic
Employee Life $
Supplemental
Employee Life $
Dependent Life $
Total
Monthly Premium $
In signing below, I (a) represent that the statements and answers given on all pages of this application, are true, complete and correctly recorded to the best of
my knowledge and belief; (b) authorize any physician, medical practitioner, hospital, clinic, or other medically related facility, insurance or reinsurance
company, or Medical Information Bureau, Inc., having information on me or any member of my family (only those who have applied for coverage on this
application) regarding our mental and physical health, other insurance coverage, hazardous activities, character, general reputation, finances, and vocation to
give to USAble Life, its reinsurers, or its legal representative any and all such information to use for underwriting insurance; (c) authorize all said sources,
except MIB, to give such records or knowledge to any agency employed by the company to collect and transmit such information in order to facilitate its rapid
submission; (d) agree that this authorization shall be valid for two (2) years from the application date; (e) agree that a photocopy of this authorization shall be
as valid as the original and I understand that a copy is available to me or my representative upon request; (f) acknowledge receipt of written notification
describing the use of the Medical Information Bureau as required by the Fair Credit Reporting Act; and (g) acknowledge receipt of the Insurance Fraud
Warning. I have read and understand the above statements and agreements. In applying for insurance, I authorize my employer to make the necessary
payroll deductions to pay for my insurance. I understand failure to disclose a proposed insured person’s true health condition may void this policy.
Insurance Fraud Warning - 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 may be guilty of a crime and subject to fines and confinement in prison.
DATE OF
APPLICATION
MONTH/DAY/YEAR EMPLOYEE SIGNATURE
SIGNATURE OF EMPLOYER/WITNESS
PRINTED NAME OF EMPLOYER/WITNESS
APSG-APP (8-11)
Page 1 of 2
Please Print Using Dark Ink
ARKANSAS PUBLIC SCHOOL
EMPLOYEES GROUP
Application, Chan
e Form & Beneficiar
Chan
e Form
For Office Use Only
Class
Dep SIC
Eff. Date
Group #
