GROUP
APPLICATION
AMERICAN FIDELITY ASSURANCE COMPANY
9000
Cameron Parkway Oklahoma City, Oklahoma 73114
1. PROPOSED INSURED
INFORMATION:
Last Name First Name Full Middle Name Suffix
Age Date of Birth
MM/DD/YYYY
Sex SSN Requested Effective Date Date of Employment
M F MM/DD/YYYY MM/DD/YYYY
Residence Address: Number & Street (Not a P.O. Box) Work Phone # Home Phone #
( ) ( )
City State Zip Country of Citizenship
Mailing Address (if different than Residence) City State Zip
Employer Name Employer/MCP # Salary: $ Occupation
Annual Monthly
Are you currently able to perform the duties of your occupation? Yes No
Spouse Last Name First Name Middle Initial SSN Date of Birth Country of Citizenship
Has any adult to be covered used any form of nicotine in the last 12 months? Applicant Yes No Spouse Yes No
Applicant’s Email Address:
2.
BENEFITS APPLIED FOR:
BENEFICIARY: Last Name
Fir
st Name
Middle Initial Relationship
Country of Citizenship
4. ELECTION: I hereby enroll, add or change, as selected above, group insurance coverage(s) for which I am eligible. I
authorize my employer to deduct my contributions, if any, from my pay.
5. ACKNOWLEDGMENT: I understand and agree that:
•
The information in this application will be used to determine my eligibility for insurance; the statements and answers
shown in this application are true and complete; the Company may rely upon such answers as the basis of my contract;
and no coverage will take effect until the application is approved by the Company, the first premium is received, and a
Certificate is issued.
• If applying for disability income coverage, OTHER INCOME I AM ENTITLED TO RECEIVE WILL, IF APPLICABLE,
REDUCE MY MONTHLY BENEFIT. I SHOULD READ MY CERTIFICATE FOR MORE DETAILED INFORMATION
REGARDING HOW OTHER INCOME WILL REDUCE MY BENEFIT.
• “Pre-Existing Conditions” may not be covered; and I should read my Certificate for a more detailed explanation of the Pre-
Existing Condition exclusion, if any. I further understand that any increase in coverage must be applied for and approved
by the company, and as explained in my Certificate, a new Pre-Existing Condition period will apply with respect to the
increase.
6. FRAUD NOTICE: Any person, who knowingly and with intent to injure or deceive any insurer, files a statement of claim
or application containing any false, incomplete, or misleading information may be guilty of insurance fraud.
BROCHURE(S) #
HAS/HAVE BEEN
EXPLAINED TO ME, AND I HAVE RECEIVED A COPY/COPIES; OR, I HAVE HAD ACCESS TO AND
THE OPPORTUNITY
TO PRINT THE BROCHURE(S).
(where required by law)
Applicant Signature or PIN
Agent #
02110A
A1275
SB-8109T-1013
City of Plano
46192
3.
Product New/Change
Persons Covered
1
Plan Code
Plan Amount
GAP Plan 018430-GTX $ 500
GAP Plan 018431-GTX $1,000
GAP Plan 018433-GTX $1,500
1
z=Individual; y=Individual & Spouse; x=Individual, Spouse & Child(ren); v=Individual & Child(ren); s=Spouse
