Fillable Form 000001: Enrollment and Statement of Health Presbyterian (Presbyterian College)

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Form 000001: Enrollment and Statement of Health Presbyterian (Presbyterian College)

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  • 34 check-boxes
  • 125 other fields

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File type: PDF

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Reliance Standard Life Insurance Company
Enrollment and Statement of Health
LRS-9457-0111 Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA
Page
1
of 3
Name of Employer
Presbyterian College
GL149523 / 01
Bill Group
000001
Location
Application Type: £ Initial Eligibility/New Hire £ Late Applicant £ Other
£ Increase £ Approved Annual Enrollment
£ Change in Status: Nature of Change(s):
Date of Change:
If marriage, divorce or birth of a child, please provide copy of document.
Employee/Member Information – Always Complete
Are you actively performing all the duties of your occupation or profession? £ Yes £ No
If “No,” explain:
Spouse Information – Complete Only If Applying for Spouse Coverage
Spouse Name
Gender
Date of Birth
Age
State of Birth
Address
City
State
Zip
Coverage Elected and Amounts
Coverage
Enroll or
Decline
1
Current
Amount
Increase or Decrease Total Amount Applied For Premium
Group Term Supplemental
Life Employee
2
£ Enroll
£ Decline
+$___________
-$___________
$___________
See
Premium
Table
Group Term Life: Spouse
3
£ Enroll
£ Decline
+$___________
-$___________
$___________
See
Premium
Table
Group Term Life: Dep.
Children
3
£ Enroll
£ Decline
+ $____________
- $____________
$___________
See
Premium
Table
1
"Enroll" authorizes employer to payroll deduct premiums.
2
Statement of Health may be required.
3
Coverage subject to election of employee coverage.
Su
bmit completed Enrol
lment
and Statement of Health form
to:
Reliance Standard
P.O. Box 7818
Philadelphia, PA 19101-7818
We do not accept faxed forms.
Name
Social Security Number
Gender
Date of Birth
Age
State of Birth
Date of Hire
Address
City
State
Zip
Ph
one Number
Occupation
Annual Compensation
Hours Worked Per Week
Email Address
LRS-9457-0111 Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA
Page
2
of 3
Employee/Member Name
Date of Birth
Health Questions
Answer all questions on this
page for each person being
underwritten for insurance.
For any "Yes" answer,
underline the condition and
record details in the space
provided on the next page.
Failure to provide details of a
condition will cause a delay in
the review of your application.
EMPLOYEE
SPOUSE
Enter height and weight.
Ht. __ft. ___in.
Wt. _____ lbs
Ht. __ft. ___in.
Wt. _____ lbs
1.
In the past 10 years, have you or your spouse b
een treated for or
diagnosed as having: heart, liver (biliary cirrhosis) or kidney
disorder; an abnormal colonoscopy requiring follow-up; neurological
disorder; diabetes; high blood pressure; thyroid disorder; stroke;
transient ischemic attack (TIA); cancer and/or tumor malignant or
benign; mental or nervous disorder; or been advised to have
treatment for drug abuse (illegal or prescription drugs) or
alcoholism?
£ Yes £ No
£ Yes £ No
2.
In the past 10 years, have you or your spouse be
en diagnosed with
or treated for: chronic pain; arthritis (lupus, rheumatoid or
osteoarthritis); musculoskeletal (back, neck or muscle) condition;
respiratory disorder including asthma, chronic obstructive pulmonary
disease (COPD); or emphysema?
£ Yes £ No
£ Yes £ No
3.
Have you or your spouse: (a) in the past year had: fever persisting
more than one month; significant involuntary weight loss; diarrhea
persisting more than one month; oral candidiasis (thrush); or
lymphadenopathy (enlarged or swollen glands)? or (b) in the past 10
years ever tested positive or been treated for HIV (Human
Immunodeficiency Virus) antibodies, AIDS or AIDS-related complex
(ARC)?
£ Yes £ No
£ Yes £ No
4.
In the past 10 years, have you or your
spouse: (a) consulted with or
been examined or treated by a physician, practitioner or specialist
(include routine physicals only when there is an existing or newly
diagnosed medical condition)? (b) been in a hospital or other facility
for observation, diagnosis, treatment or an operation? or (c) been
prescribed medication(s) (other than for colds, flu or allergies)?
£ Yes £ No
£ Yes £ No
5.
Are you currently pregnant? In the past 10 years, have you or your
spouse been diagnosed with: abnormal uterine bleeding; abnormal
pap smear; abnormal mammogram requiring additional studies or
with recommendation of breast biopsy?
£ Yes £ No
£ Yes £ No
Employee/Member Primary Care Physician's Full Name
Office Phone Number
Address
Spouse Primary Care Physician's Full Name
Office Phone Number
Address
LRS-9457-0111 Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA
Page
3
of 3
Employee/Member Name
Date of Birth
Details
Please provide all names used for medical records (if different than the names provided on this form):
For each “Yes” response to a health question, please provide details below.
Question #
Illness or Nature of Injury
Date
Physician’s Full Name and Address
(if different than Primary)
Check One
Employee or Spouse
If you need more space, check here £. Complete, sign and date a separate sheet of paper and attach it to this page.
Read, Sign and Date Below
I understand and agree that:
• The information provided on this Enrollment and Statement of Health form is true and correct to the best of my knowledge.
• The insurance requested will become effective in accordance with the individual effective date information in the Policy; any amount
subject to evidence of insurability will not become effective until approved by Reliance Standard and Reliance Standard has the right to
refuse my request. Coverage is subject to a minimum participation requirement at the employer level and if the minimum is not met,
coverage may not be issued even though an enrollment form has been completed. An effective date is subject to eligibility requirements,
satisfaction of service waiting period (if applicable) and payment of first premium when due. An effective date may be deferred for an
employee not actively at work and enrolled dependents confined to a hospital or at home.
• Benefits are subject to terms and conditions of the Policy.
• For age-banded rate plans, premiums increase as an employee (or spouse, if applicable) moves from one age band to the next.
• If payroll deduction of premiums begins prior to Reliance Standard’s processing of the enrollment form, it does not mean coverage is in
effect; premiums paid for coverage not issued will be returned.
I further understand and agree that if I am applying after the expiration of my initial eligibility period, all medical tests and costs for
attending physician reports may be without expense to Reliance Standard Life Insurance Company and I may be responsible for paying
the expenses, if any.
I acknowledge receipt of the "Designation of Beneficiary" form and “Important Information Regarding Applications for Insurance” and “Notice
Regarding Information Practices”. If a Designation of Beneficiary form is not completed or one is not on file with the Plan Administrator, the
provisions of the Policy will determine to whom benefits, if any, will be payable.
AUTHORIZATION: I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance
company, organization, institution, person or the Medical Information Bureau (MIB) to release any information or record(s) on me or my health to be
used in determining the acceptability of my application for insurance. I authorize any such information or record(s) to be released to Reliance
Standard Life Insurance Company, its reinsurers or authorized representatives. I also authorize Reliance Standard or its reinsurers to make a brief
report of my personal health information to the MIB. This authorization, or a photographic copy, shall be as binding as the original and valid for a
period not exceeding twelve (12) months from this date. I understand that I (or my authorized representative) will be sent a copy of this Authorization
upon request.
Please Note: During an approved enrollment, guaranteed issue amounts of insurance will not require a Statement of Health form provided the
Enrollment form is complete, signed and received by your employer during your enrollment period and: a) you are not a late applicant with respect to
insurance for yourself (and/or your spouse, if applicable); or b) during your present service with your employer or an affiliate, you (and/or your
spouse, if applicable,) have not, with respect to insurance with Reliance Standard or an affiliate: had an application withdrawn; been previously
declined; had coverage postponed; or voluntarily terminated; or c) the enrollment period is not one with specific guaranteed issue/health acceptability
rules.
X ____________________________________ _______________
Employee’s/Member's Signature Date
(required at all times)
X ____________________________________ _______________
Spouse’s Signature Date
(required if spouse Statement of Health required)
click to sign
signature
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signature
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EF
-
1245
Designation of Beneficiary
Policyholder
Policy Number(s)
Insured Name
Social Security Number
I hereby designate the following as my beneficiary (ies) under the above policy number(s):
Primary Beneficiary(ies)
Full Name and Address (Please Print)
Percentage*
(Must total 100%)
Date of Birth Relationship Social Security Number
* If no percentages are indicated, benefits will be divided equally between all primary beneficiaries.
Contingent Beneficiary(ies) (applicable only if you are not survived by one or more primary beneficiaries)
Full Name and Address (Please Print)
Percentage*
(Must total 100%)
Date of Birth Relationship Social Security Number
* If no percentages are indicated, any benefits payable to contingent beneficiaries will be divided equally between all
contingent beneficiaries.
♦ This beneficiary designation revokes all revocable prior beneficiary designations.
♦ Unless you indicate otherwise, if any beneficiary predeceases you, that beneficiary's share will be divided pro-rata
among the surviving beneficiaries of the same class (primary or contingent).
♦ If no beneficiary (primary or contingent) survives you, payment will be made pursuant to the terms of the
applicable policy.
Date
Signature of Insured
Important Information Regarding Applications for Insurance
The information provided on the Enrollment and Statement of Health form will be used in determining the insurability of a person
proposed for insurance. Responsible parties completing and submitting a Statement of Heath form are required to be made aware of
the following statements concerning the consequences of insurance fraud. The lack of an applicable statement shall not constitute a
defense against penalties.
ARKANSAS and LOUISIANA — 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 is guilty of a crime and may be subject to fines and confinement in
prison. COLORADO — It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete,
or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder
or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of
Insurance within the Department of Regulatory Agencies. FLORIDA — 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. KENTUCKY — Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance 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. MAINE — It is a crime to
knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.
Penalties may include imprisonment, fines or a denial of insurance benefits. MARYLAND — 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. NEW JERSEY — Any person
who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
NEW MEXICO — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefits or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NEW YORK (health insurance only) — Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim 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, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO — Any
person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud. PENNSYLVANIA — Any person who knowingly and with
intent to defraud any insurance company or other person files an application for insurance or statement of claim 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, and subjects such person to criminal and civil penalties. RHODE ISLAND — 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 is guilty of a crime and may be subject to fines and confinement in prison. TENNESSEE, VIRGINIA,
WASHINGTON — It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. WASHINGTON, DC
— WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any
other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.
KEEP THIS INFORMATION PAGE FOR YOUR RECORDS.
Home Office: Chicago, Illinois
Administrative Office: Philadelphia, Pennsylvania
NOTICE REGARDING INFORMATION PRACTICES
In considering this Application, Reliance Standard Life Insurance Company ("we", "us" or "our") collects certain information about all proposed
insureds ("you" or "your"). The precise information varies according to the amount and type of coverage you apply for. Generally, we seek
information about your: (1) age; (2) occupation; (3) physical condition; (4) medical history; (5) hobbies; and (6) other relevant activities.
You are the most important source of information, but we may also verify or collect information on you or your family from: (1) physicians; (2) other
health care providers; (3) employers; (4) other insurers to which you have applied; (5) consumer investigative organizations; and (6) the Medical
Information Bureau ("MIB").
The MIB is a not-for-profit organization of life insurance companies which operates an information exchange for its members. This information may
alert us to a need for further investigation, but under MIB rules such information cannot be used: (1) either wholly or in part to increase the premium
for insurance; or (2) to deny issuance of insurance.
We may collect information by: (1) phone; (2) correspondence; or (3) personal contact.
Information will be treated as confidential. Reliance Standard Life Insurance Company or its reinsurers may, however, with your authorization make
a brief report to the MIB. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to
such a company, the MIB, upon request, will supply such company with the information in its file. The information supplied to other member
companies may alert them to a need for further investigation.
In some circumstances, however, information may be released to third parties without your authorization (with the exception of the MIB). These
include persons or organizations who are: (1) performing business functions for us; (2) conducting actuarial or scientific studies or audits; or (3) our
reinsurers. We or our reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance
coverage, or to whom a claim for benefits is submitted. Please be assured that although such disclosures may occur, they are not always or even
often made. When a disclosure is necessary, only as much information as is reasonably necessary to achieve the intended purpose will be
disclosed.
You have the right to acquire and, if necessary, correct any personal information we or the MIB collect. Upon written request to us, we will within 30
days of receipt: (1) inform you of the nature and substance of the recorded information; (2) permit personal viewing and copying of the information in
our possession; (3) disclose the identities of those persons such information has been disclosed to within the last two years; and (4) provide you with
procedures for correction, amendment or deletion of the recorded information. Medical information will be disclosed to a physician that you choose.
You may write to us for a fuller explanation of our information practices.
You may also contact the MIB via its website (www.mib.com) or by telephone to arrange for disclosure of any information it may have on you. The
MIB's toll-free telephone number is 866-692-6901 (TTY 866-346-3642 for hearing impaired). If you question the accuracy of information in the MIB's
file, you may contact the MIB in writing and seek correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The
address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184-8734.
KEEP THIS NOTICE FOR YOUR RECORDS.
Home Office: Chicago, Illinois
Administrative Office: Philadelphia, Pennsylvania
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Form 000001: Enrollment and Statement of Health Presbyterian (Presbyterian College)

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Completed 23 July 2020

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