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HE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA T (ASA College)

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1
DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER
DATE FORM PUBLISHED: Jul 26, 2019
Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com
Group Insurance Enrollment Form
Page 1 of 8
Guardian Life, P.O. Box 14319,
Lexington, KY 40512
Please print clearly and mark carefully.
CEF2016-NY
T
HE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA
Employer Name: ASA COLLEGE, INC. Group Plan Number: 00552466
Benefits E ffective:_____________
PLEASE CHECK APPROPRIATE BOX q Initial Enrollment q Re-Enrollment q Add Employee/Dependents q Drop/Refuse Coverage q Information Change
q Increase Amount q Family Status Change
Class: ALL ELIGIBLE NON
EXECUTIVE FULL TIME EMPLOYEES
Division:_________________
Subtotal Code:____________________ (Please obtain this from your Employer)
About You:
First, MI, Last Name:
Social Security Number
__ ___ ___ - ___ ___ - ___ ___ ___ __
Address City State Zip
Gender: q M q F
Date of Birth (mm-dd-yy): ____ - ____ - ____
Phone:
Email Address: Are you married or do you have a spouse? q Yesq No
Do you have children or other dependents? q Yesq No
Date of marriage/union:____-____-_____
Placement date of adopted child: ____-____-
_____
About Your Job:
Hours worked per week: _______ Job Title:
Work Status:
q Active q Retired q Cobra/State Continuation
Date of full time hire: ____ - ____ - ____
Annual Salary: $____________
About Your Family:
Please include the names of the dependents you wish to enroll for coverage. A dependent is a person who
relies on you for financial support; and for whom you qualify for a dependent tax exemption. Dependent tax exemptions are
subject to IRS rules and regulations. Additional information may be required for non-standard dependents such as a grandchild,
a niece or a nephew.
Spouse (First, MI, Last Name)
Address/City/State/Zip:
Phone: ( ) -
Gender
q M q F
Social Security Number
_____ - _____ - _____
Date of Birth (mm-dd-yyyy)
____ - ____ - ____
Child/Dependent 1:
Address/City/State/Zip:
Phone: ( ) -
q Add q Drop
Gender
q M q F
Social Security Number
_____ - _____ - _____
Date of Birth (mm-dd-yyyy)
____ - ____ - ____
Status (check all that apply)
q Student (post high school) q Disabled
q Non standard dependent
Child/Dependent 2:
Address/City/State/Zip:
Phone: ( ) -
q Add q Drop
Gender
q M q F
Social Security Number
_____ - _____ - _____
Date of Birth (mm-dd-yyyy)
____ - ____ - ____
Status (check all that apply)
q Student (post high school) q Disabled
q Non standard dependent
2
DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER
Child/Dependent 3:
Address/City/State/Zip:
Phone: ( ) -
q Add q Drop
Gender
q M q F
Social Security Number
_____ - _____ - _____
Date of Birth (mm-dd-yyyy)
____ - ____ - ____
Status (check all that apply)
q Student (post high school) q Disabled
q Non standard dependent
Child/Dependent 4:
Address/City/State/Zip:
Phone: ( ) -
q Add q Drop
Gender
q M q F
Social Security Number
_____ - _____ - _____
Date of Birth (mm-dd-yyyy)
____ - ____ - ____
Status (check all that apply)
q Student (post high school) q Disabled
q Non standard dependent
Drop C overage:
q Drop Employee q Drop Dependents
T he date of withdrawal cannot be prior to the date this form is
completed
Last Day of C overage: _____-_____-_____
q Termination of Employment q Retirement
Last Day Worked: _____-_____-____
q Other Event: _____________
Date of E vent: _____-_____-_____
Coverage Being Dropped:
q Dental q Employee q Spouse q Child(ren)
q Vision q Employee q Spouse q Child(ren)
q Basic Life
q Voluntary Life q Employee q Spouse q Child(ren)
q Specified Disease
q Accident q Employee q Spouse q Child(ren)
q Long Term Disability
Loss Of Other Coverage:
I and/or my dependents were previously covered under another insurance
plan
. Loss of coverage was due to:
q Termination of Employment:
q Divorce
q Death of Spouse
q Termination/Expiration of Coverage _____-_____-_____
Coverage Lost q Dental q Vision
I have been offered the above coverage(s) and wish to drop enrollment for the following
reasons:
q Covered under another insurance plan
q Other ____________________________________________________
(additional information may be required)
Dental Coverage: You must be enrolled to cover your dependents. Check only one box.
Employee Only Employee and 1
Dependent
EE, Spouse &
Dependent/Child(ren)
PPO q q q
q I do not want this coverage. If you do not want this Dental Coverage, please mark all that apply:
q I am covered under another Dental plan
q My spouse is covered under another Dental plan
q My dependents are covere
d under another Dental plan
Vision Coverage: You must be enrolled to cover your dependents. Check only one box.
Your Bi-weekly Premium Employee Only Employee and 1
Dependent
EE, Spouse &
Dependent/Child(ren)
Full Feature - Designer q $2.43 q $3.69 q $6.49
q I do not want this coverage. If you do not want this Vision Coverage, please mark all that apply:
q I am covered under another Vision plan
q My spouse is covered under another Vision plan
q My dependents are covered under another Vision plan
Guardian Group Plan Number: 00552466 Please print employee name:
DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER
Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com
3
Basic Life Coverage:
Benefit reductions apply. Please see plan administrator.
P
olicy Amount
Emplo
yee Only
R 100% of your annual
salary to a maximum of
$100,000
The Guarantee Issue
Amount is $100,00
0.
Name your beneficiaries: (Primary beneficiary percentages must total 100%)
Primary Beneficiaries:
Name:
Social Security Number:____ __-____-______%
Date of Birth (mm-dd-yy):___-___-___Address/City/State/Zip:
Relationship to Employee:_
Phone: ( )
-Name:
Social Security Number:____ __-____-______%
Date of Birth (mm-dd-yy):___-___-___Address/City/State/Zip:
Relationship to Employee:_
Phone: ( ) -
Contingent Beneficiary:
Social Security Number:____-__ __-_____
Date of Birth (mm-dd-yy):___-___-___Address/City/State/Zip:
Phone: ( ) - Relationship to Employee:
(In the event the primary beneficiaries are deceased, the contingent beneficiary will receive
the benefit. Employer maintains beneficiary information.)
If this Basic Life policy is intended to replace your existing life insurance policy under your current employer, provide the amount of the previous policy $____________
Important Notes:
Based on your plan benefits and age, you may be required to complete an evidence of insurability form for Basic Life.
Voluntary Term Life Coverage: You must be enrolled to cover your dependents. Benefit reductions apply. Please see plan administrator.
E mployee
Policy Amount Check one box only
q $25,000 q $50,000 q $75,000 q $100,000 q $125,000 q $150,000*
q $175,000 q $200,000 q $225,000 q $250,000
*Guarantee Issue Amount. The Health History section must be completed if any amount above the Guarantee Issue Amount is elected.
q I do not want this coverage
Add Voluntary Life for Spouse
Policy Amount
q $25,000* q $50,000 q $75,000 q $100,000 q $125,000 q $150,000
q $175,000 q $200,000 q $225,000 q $250,000
*Guarantee Issue Amount
*The amount may not be more than 100% of the employee amount for Voluntary Life.
q I do not want this coverage
Add Voluntary Life for Dependent/Child(ren)
Policy Amount
q $1,000 q $2,000 q $3,000 q $4,000 q $5,000 q $6,000
q $7,000 q $8,000 q $9,000 q $10,000*
*Guarantee Issue Amount
*The amount may not be more than 10% of the employee amount for Voluntary Life.
q I do not want this coverage
Important Notes:
Based on your plan benefits and age, you may be required to complete an evidence of insurability form for Voluntary Life.
4
LIFE INSURANCE continued
Name your beneficiaries: (Primary beneficiary percentages must total 100%) If electing different beneficiaries that are not the same as those named for Basic Life,
please name below.
Primary Beneficiaries:
Name:
Date
of
Birth
(mm-dd-yy):
____
-
____
-
____
Social Security Number:___ ___ ___-___ ___-___ ___ ___ ___ %
Address/City/State/Zip:
Phone:
Relationship to Employee:_
Name:
Date of Birth (mm-dd-yy):____-____-____
Social Security Number:___ ___ ___-___ ___-___ ___ ___ ___ %
Address/City/State/Zip:
Phone:
Relationship to Employee:_
Social Security Number: ___ ___ ___-___ ___-___ ___ ___ ___
Contingent Beneficiary:
Date of Birth (mm-dd-yy):____-____-____
Address/City/State/Zip:
Phone:
Relationship to Employee:_
(In the event the primary beneficiaries are deceased, the contingent beneficiary will receive the benefit. Employer maintains beneficiary information.)
Spouse and dependent/child(ren)  If the intended beneficiary is to be someone other than the employee, please complete the Beneficiary Designation form.
Long-Term Disability (LTD) Coverage:
Monthly Benefit
R 60% of salary to a maximum of $5,000
Specified Disease Coverage: You must be enrolled to cover your dependents
YOU MUST HAVE AT LEAST MAJOR MEDICAL INSURANCE OR AT LEAST BASIC HOSPITAL INSURANCE AND BASIC MEDICAL INSURANCE ON THE DATE OF THIS
APPLICATION FOR SPECIFIED DISEASE COVERAGE. YOUR SIGNATURE AT THE END OF THIS FORM STATES THAT SUCH COVERAGE IS INFORCE ON SUCH DATE.
Benefit reductions apply. Please see plan administrator.
Employee
Insurance Amount:
q $5,000 q $10,000 q $15,000 q $20,000 q $25,000
q I do not want this coverage.
Spouse
Insurance Amount: Up to 50% of the employee's amount to a maximum of $12,500
q $2,500
q $5,000 q $7,500 q $10,000 q $12,
500
q I do not want this coverage.
Dependent/Child(ren)
Insurance Amount: q 25% of the employee's amount
q I do not want this coverage.
Guardian Group Plan Number: 00552466 Please print employee name:
DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER
Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com
5
I UNDERSTAND THAT THIS IS SPECIFIED DISEASE INSURANCE. THIS IS A SUPPLEMENT TO HEALTH IN
SURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDIAL
COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. I
ACKNOWLEDGE THAT I HAVE COMPREHENSIVE HOSPITAL, SURGICAL AND MEDICAL HEALTH INSURANCE (MINIMUM ESSENTIAL COVERAGE).
Please acknowledge below.
Employee: _____ Yes ______ No
Spouse: _____ Yes ______ No ______ N/A* *Select N/A only if not enrolling this dependent
Child(ren): _____ Yes ______ No ______ N/A* *Select N/A only if not enrolling this dependent. For a Yes response, proceed to the next section. For any No response,
a certificate will be issued.
If you have questions about the benefits provided by this coverage, then please contact us at 888-600-1600.
Do you have on the date of this application, other specified disease coverage in force(or pending applications) for the same disease(s) for which you are applying for
coverage herein for you and any dependents being enrolled? q Yes. q No.
Please indicate the number of specified diseases for which you have coverage in force(or pending applications)for yourself and any dependents being enrolled
Employee_____________ Dependents:___________
If you or your dependent spouse elect Specified Disease and elect an amount above the Guaranteed Issue amount, you must answer the following health questions.
1. Has any proposed insured been diagnosed with or treated by a medical professional for any of the following conditions: cancer, carcinoma in situ,malignant melanoma,
tumor (benign or malignant), Barretts esophagus, Crohns disease, ulcerative colitis, blood disorder (other than AIDS or HIV), any chronic or progressive disease of kidneys,
liver (including hepatitis), lungs, including emphysema and COPD, pancreas or bone marrow? Or, been advised to have an organ transplant, including bone marrow or stem
cell transplant?
Employee
q Yes q No Spouse q Yes q No
2. Has any proposed insured been diagnosed with or treated by a medical professional for heart attack, he
art disease or coronary artery disease, stroke or transient ischemic
attack (TIA), or been advised to have bypass surgery, stent insertions or treatment for coronary arteries?
Employee q Yes q No Spouse q Yes q No
3. Has any proposed insured been diagnosed with or treated by a medical professional for uncontrolled blood pressure (requiring a change in medication or dosage in the
past 6 months or been diagnosed with or treated for diabetes (except if present only in pregnancy)?
Employee q Yes q No Spouse q Yes q No
4. Has any proposed insured been diagnosed with or treated by a medical professional for AIDS (acquired immune deficiency syndrome), or AIDS-Related Complex?
Employee q Yes q No Spouse q Yes q No
IMPORTANT NOTES:
Based on your plan benefits and age, you may be required to complete an additional evidence of insurability form for Specified Disease.
No later than 30 days following delivery of specified disease coverage, Guardian will ask in a written request whether at least major medical insurance or at least
basic hospital insurance and basic medical insurance (required underlying coverage) is in force on the effective date of the specified disease coverage. If Guardian
receives a written response that the required underlying coverage is not in force for an insured person on the effective date of the specified disease coverage, the
specified disease coverage for that insured person will be voided from its beginning with a full premium refund for such person.
Accident Coverage You must be enrolled to cover your dependents.
YOU MUST HAVE AT LEAST COMPREHENSIVE HOSPITAL, SURGICAL AND MEDICAL INSURANCE ON THE DATE OF THIS APPLICATION FOR ACCIDENT COVERAGE.
YOUR SIGNATURE AT THE END OF THIS FORM STATES THAT SUCH COVERAGE IS INFORCE ON SUCH DATE.
NOTICE: This coverage under the policy may only be issued if you have minimum essential coverage within the meaning of section 500A(f) of the Internal Revenue Code.
I UNDERSTAND THAT THIS IS SPECIFIED DISEASE INSURANCE. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDIAL
COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. I
ACKNOWLEDGE THAT I HAVE COMPREHENSIVE HOSPITAL, SURGICAL AND MEDICAL HEALTH INSURANCE (MINIMUM ESSENTIAL COVERAGE).
Please acknowledge below.
Employee: _____ Yes ______ No
Spouse: _____ Yes ______ No ______ N/A* *Select N/A only if not enrolling this dependent
Child(ren): _____ Yes ______ No ______ N/A* *Select N/A only if not enrolling this dependent. For a Yes response, proceed to the next section. For any No
response, a certificate will be issued.
If you have questions about the benefits provided by this coverage, then please contact us at 888-600-1600.
Your Bi-weekly premium Employee Only EE & Spouse EE &
Dependent/Child(ren)
EE, Spouse &
Dependent/Child(ren)
q $3.44 q $5.63 q $5.67 q $7.86
6
q I do not want this coverage.
N
ame your beneficiaries: (Primary beneficiary percentages must total 100%)
Primary Beneficiaries:
Name:
Date of Birth (mm-dd-yy):____-____-____
Social Security Number:___ ___ ___-___ ___-___ ___ ___ ___ %
Address/City/State/Zip:
Phone:
Relationship to Employee:_
Name:
Date of Birth (mm-dd-yy):____-____-____
Social Security Number:___ ___ ___-___ ___-___ ___ ___ ___ %
Address/City/State/Zip:
Phone:
Relationship to Employee:_
Social Security Number: ___ ___ ___-___ ___-___ ___ ___ ___
Contingent Beneficiary:
Date of Birth (mm-dd-yy):____-____-____
Address/City/State/Zip:
Phone:
Relationship to Employee:_
(In the event the primary beneficiaries are deceased, the contingent beneficiary will receive the benefit. Employer maintains beneficiary information.)
Spouse and dependent/child(ren)  If the intended beneficiary is to be someone other than the employee, please complete the Beneficiary Designation form.
Signature
l An employee's decision to elect Vision or not elect Vision must be retained until the next plan's Open Enrollment period. If the employee elects not to enroll in vision
coverage, they are not eligible to enroll until the plan's next Open Enrollment period.
l I understand that life insurance coverage for a dependent, other than a newborn child, will not take effect if that dependent is confined to a hospital or other health care
facility, or is home confined, or is unable to perform the normal activities of someone of like age and sex.
l I understand that my dependent(s) cannot be enrolled for a coverage if I am not enrolled for that coverage.
l I understand that the premium amounts shown above are estimations and are for illustrative purposes only.
l Submission of this form does not guarantee coverage. Among o
ther things, coverage is contingent upon underwriting approval and meeting the applicable eligibility
requirements as set forth in the applicable benefit booklet.
l I understand that I must be actively at work or my elected coverage will not take effect until I have met the eligibility requirements (as defined in the benefit booklet.) This
does not apply to eligible retirees.
l If coverage is waived and you later decide to enroll, late entrant penalties may apply. You may also have to provide, at your own expense, proof of each person's
insurability. Guardian or its designee has the right to reject your request.
l Plan design limitations and exclusions may apply. For comple
te details of coverage, please refer to your benefit booklet. State limitations may apply.
l I hereby apply for the group benefit(s) that I have chosen above.
l I understand that I must meet eligibility requirements for all coverages that I have chosen above.
l I agree that my employer may deduct premiums from my pay if they are required for the coverage I have chosen above.
l I agree that my [employer] or my employers designated administrator may deduct premiums from my pay apply premiums to my credit card or debit card add
premiums to my dues withdraw premiums from my designated bank account, apply premiums to my credit or debit card if they are required for the coverage I have
chosen.
l I acknowledge and consent to receiving electronic copies of insurance related documents, in lieu of paper copies, to the extent permitted by applicable law
q I voluntarily agree to that arrangement. q I do not agree to that arrangement. I understand that I may change my election by providing Guardian 30 day prior
written notice.
l I state that the information provided above is true and correct to the best of my knowledge.
I understand that this is a supplemental accident-only policy and that it does not p
rovide coverage for and is not intended to replace comprehensive hospital, surgical and
medical insurance. I understand that this policy does not provide coverage for sickness. I acknowledge that I have comprehensive hospital, surgical and medical insurance.
If you have questions about the benefits provided by this coverage, please contact us at 1-800-541-7846.
Guardian Group Plan Number: 00552466 Please print employee name:
DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER
Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com
7
Any person who with intent to defraud any insurance company or other person files an applicat
ion for insurance or statement of claim containing any materially,
false information, or conceals for purpose of misleading information concerning any fact material hereto, commits a fraudulent insurance act, which is a crime, and
may also be subject to civil Penalties, or denial of insurance benefits (Does not apply to Life Insurance).
Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. A discount is associated with the accelerated death
benefits. A fee of up to $250.00 will be required for the administrative cost of evaluating and processing Your application for this benefit.
The Policy permits the group Policyholder to change, reduce, restrict or terminate Your rights or benefits under the Policy without Your consent; and b) such change,
reduction, restriction or termination may occur at a time when Your health status has changed and may affect Your ability to procure individual coverage.
The state in which you reside may have a specific state fraud warning. Please refer to the attached Fraud Warning Statements page.
The laws of New York require the following statement appear: 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. (Does not apply to Life Insurance.)
The following section applies to these coverage(s):Basic Life, Voluntary Life
READ YOUR CERTIFICATE CAREFULLY,CERTAIN WAR RISKS ARE NOT ASSUMED.IN CASE OF ANY DOUBT,CONTACT YOUR COMPANY FOR FURTHER
EXPLANATION.
The following section applies to these coverage(s): Accident Coverage, Specified Disease Coverage, Hospital Indemnity Coverage:
NOTICE TO CONSUMER: THIS COVERAGE IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR
MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. ALSO, THE BENEFITS PROVIDED BY
THIS POLICY CANNOT BE COORDINATED WITH THE BENEFITS PROVIDED BY OTHER COVERAGE. PLEASE REVIEW THE BENEFITS PROVIDED BY THIS POLICY CAREFULLY
TO AVOID A DUPLICATION OF COVERAGE.
SIGNATURE O F EMPLO YE E X
___________________________________________ DATE ______________________
Enrollment Kit 00552466, 0002, EN
F raud Warning Statements
The laws of several states require the following statements to appear on the enrollment form:
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment
of a loss is subject to criminal and civil penalties.
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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy
holder 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.
Connecticut, Iowa, Nebraska, and Oregon: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of insurance
or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of
a fraudulent insurance act, which may be a crime, and may also be subject to civil penalties.
Delaware, Indiana and Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia: 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.
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.
Kansas: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of insurance or statement of claim containing any
materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of insurance fraud as determined by a
court of law.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a 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.
Louisiana and Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to fines and
confinements in state prison.
Maine, Tennessee and 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.
click to sign
signature
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8
Maryland : Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Rhode Island: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or 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.
Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or
misleading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. § 638:20
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
New Mexico: Any person who knowingly presents a false or fraudulent claim for payment or a loss or benefit 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 or denial of insurance benefits.
Ohio: Any person who with intent to defraud or knowing that he/she 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.
Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
Virginia: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or
deceptive statement may have violated state law.
NY 2014 MCVF
SPECIFIED DISEASE AND/OR ACCIDENT COVERAGE - MEDICAL COVERAGE VERIFICATION FORM
If you have elected Specified Disease and/or Accident coverage with Guardian, please return this form no later than 30
days after your coverage effective/renewal date.
On the effective/renewal date of the Specified Disease coverage, is at least major medical insurance or at least basic
hospital insurance and basic medical insurance (required underlying coverage) in force for yourself and any dependents
enrolled for Specified Disease coverage with Guardian?
Yes
No
This coverage not elected
On the effective/renewal date of the Accident coverage, is at least comprehensive hospital, surgical and medical
insurance (required underlying coverage) in force for yourself and any dependents enrolled for Accident coverage with
Guardian?
Yes
No
This coverage not elected
If Guardian receives a written response that the required underlying coverage is not in force for an insured person on
the effective/renewal date of the Specified Disease and/or Accident coverage, the Specified Disease and/or Accident
coverage for that insured person will be voided from its beginning with a full premium refund for such person or in the
case of renewal, this coverage will not be renewed.
_________________________________
Signature of Employee
_________________________________
Printed Name
_________________________________
Policyholder Name
_________________________________
Policyholder Number
Keep a copy for your records and return form to:
Guardian Life
P.O. Box 14319
L
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ng
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n
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5
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2
33
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signature
click to edit
Please retain a copy for your records and submit this form to Guardian
EOI2012-NY-R
GG-016698-NY (11/14)
And its Affiliates and Subsidiaries
PO Box 14319
Lexington, KY 40512
GROUP TERM LIFE AND DISABILITY
EVIDENCE OF INSURABILITY FORM
Page 1 of 6
Please complete this form in ink. Erasures and changes invalidate this form.
Planholder Name (Company Name) Group Plan No.
Complete the following information for each person to be underwritten:
Name (Last, First, Middle Initial) Sex Birthdate Height Weight Full time Student
Employee: M
F Yes No
Employee Home Address: Preferred Method of Contact: Employee Telephone Number:
Date of Hire: Cell Phone: E-mail Address:
Spouse: M
F
Birthdate Height Weight
Yes No
Child: M
F
Birthdate Height Weight
Yes No
Child: M
F
Birthdate Height Weight
Yes No
Employee’s Social Security Number: Date of Marriage: Employee’s Place of Birth (State):
Employee Amount of Insurance Currently Inforce: Spouse Amount of Insurance Currently Inforce: Child Amount of Insurance Currently Inforce:
Employee’s Insurance Amount Elected: Spouse Insurance Amount Elected: Child Insurance Amount Elected:
Section I: IF APPLYING FOR LIFE INSURANCE, questions 1-5 must be answered by each person applying for coverage to the best of the
applicant’s knowledge and beliefs. However, if applying for coverage for a child, the Employee must complete questions 1-5 for the child
applying for coverage. IF APPLYING FOR DISABILITY INSURANCE, questions 1-5 must only be answered by the Employee.
1. In the past 10 years, has any proposed insured been treated for or diagnosed as having any of the following: a) any
disorder or condition of the heart; liver, kidney(s); lung or respiratory system; b) any disorder or condition of your
digestive system including your esophagus, stomach, or intestines; c) any mental, nervous, emotional or neurological
disorder or condition; d) auto immune disorder; e) diabetes; f) cancer; or g) a stroke?;
Employee
Yes No
Spouse
Yes No
Child
Yes No
2. In the past 5 years, has any proposed insured: used any illegal drugs; used prescription medication other than as
prescribed; been treated for alcoholism or drug use or dependency; or been advised to seek treatment for alcoholism,
drug abuse or drug dependency?
Employee Yes No
Spouse
Yes No
Child
Yes No
3. Has any proposed insured been treated for or diagnosed by a licensed member of the medical profession as having
Human Immuno-deficiency Virus (HIV); Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex
(ARC)?
Employee
Yes No
Spouse
Yes No
Child
Yes No
4. In the past year, has any proposed insured: (a) consulted or been examined by or treated by a physician, practitioner
or specialist for any illness or injury, disease or disorder NOT listed in the questions above (including routine physicals
only when there is an existing or newly diagnosed medical condition); or (b) sought treatment or a consultation in a
hospital or other health care facility for observation, diagnosis, treatment or an operation; undergone any diagnostic
testing including but not limited to X ray, blood work, ultrasound, an MRI, a CT scan, or PET scan with abnormal
findings; or been prescribed medication(s) – (other than for colds, flu or allergies)?
Employee
Yes No
Spouse
Yes No
Child
Yes No
5. If applying for disability coverage, please complete these additional questions:
(a) In the past 5 years, has any proposed insured been treated for any disorder or condition of the back, neck, spine;
arthritis; or any muscular skeletal disorder or condition?
(b) Are you currently pregnant?
Employee
Yes No
Employee
Yes No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA
This form is only required if applying for more than Guaranteed Issue Amount, OR if you
are a Late entrant and you reply "YES" to either of the
Conditional Issue questions on the other form.
Please retain a copy for your records and submit this form to Guardian
EOI2012-NY-R
GG-016698-NY (11/14)
Page 2 of 6
For each “yes” answer to question 1 through 5 give details below. (Continue on reverse side if additional space is needed.)
Question #
Name
Test, Injury, Illness, Disease,
Operation or Complication
Date of
Full Details (including Doctors’ Names
and Addresses)
Onset / Recovery
Please retain a copy for your records and submit this form to Guardian
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Page 3 of 6
Representations of the Proposed Insured(s) and Authorization Please read and sign below.
Part I. Representations of the Proposed Insured
Those parties who sign below hereby represent that the statements and answers to the question(s) are, to the best of the knowledge and belief of the
party signing below, full, complete, true and correctly recorded. Those parties who sign below understand that they will form the basis of any coverage
under the Group Plan for which Evidence of Insurability is required. When used in this Part I, “I” refers to the person applying for insurance signing
below.
Also, it is mutually understood and agreed that (1) the Company reserves the right to request, at its expense (except in the case of a late entrant, it is
not at the Company’s expense), that any proposed insured be examined by an accredited medical examiner selected by the Company; (2) no Group
Insurance will be binding or in force until satisfactory evidence of insurability is submitted, approved by the Company and the required premiums are
received by the Company; and: (a) I am actively at work on a full-time basis (as defined in the Group Plan) for full pay on the date my Group Insurance
becomes effective; otherwise, (b) I become insured on the date I do return to work and satisfy a waiting period (as defined in the Group Plan) of full-time
service; (3) coverage for my dependents will not take effect if a dependent other than a newborn is: (a) confined to the hospital or other health care
facility; or (b) is unable to perform the normal activities of someone of like age and sex; (4) no person, except the President, a Vice President or a
Secretary of the Company, has authority to: (a) determine whether any contract(s) of insurance shall be issued on the basis of the application; (b) waive
or modify any of the provisions of the application or any of the Company’s requirements; (c) bind the Company by any statement or promise pertaining
to any insurance contract(s) issued or to be issued on the basis of the application; or (d) accept any information or representation not contained in the
written application; (5) the employer is hereby named the Proposed Insured’s representative for the purpose of receiving premiums and remitting them
to the Company. In the event the Company receives premiums in excess of the appropriate amount for the coverage provided, the Company will only be
liable for the overpaid premiums plus applicable interest.
For Life Insurance Coverage Only: Material misrepresentations made by the insured relating to that person’s insurability may be used in contesting the
validity of the individual coverage with respect to which such statement was made within the first two years coverage issued based on this Evidence of
Insurability Form is in effect, only if the statement is in a signed writing that is furnished to the insured or the insured’s beneficiary.
For Coverages Other Than Life Insurance: Any misrepresentation or omission, if found to be material, may adversely affect acceptance of the risk,
claims payment or may lead to rescission of any coverage issued based on this Evidence of Insurability Form.
Part II. Authorization to Obtain Information (Medical Records and other information)
I authorize my physician, medical practitioner, hospital, clinic, other health facility, practitioner, mental health professional, pharmacy or pharmacy
benefit manager, laboratory, the MIB, Inc., insurance or reinsurance company, group policyholder, benefit plan administrator, employer, other
organization, institution or person that has any records or knowledge of the Proposed Insured or his/her health, business associate, other person or
organization to release any and all medical and non-medical information in its possession about me, to The Guardian Life Insurance Company of
America or its legal representatives. Medical information means all information in the possession of or derived from providers of health care regarding
the medical history, pharmaceutical history, and all past and present physical, mental condition, or treatment of me. Non-medical information includes
employment history, job duties, and any wage or earnings information. I understand that the information released could contain reference to the
symptoms, evaluation, diagnosis, examination, treatment or prognosis of any mental or physical condition, including psychiatric, and psychological
conditions. I understand that medical and non-medical information that can be released does not include drug and alcohol records and psychotherapy
notes. I understand that a separate authorization is required for these types of medical records.
I understand that Guardian will use the information obtained by this authorization to determine eligibility for insurance or eligibility for benefits under an
existing plan. I further understand that if I refuse to sign this authorization, the Company may not be able to process my application. Guardian will not
release any information obtained to any person or organization except to reinsurance companies, the MIB, Inc., or other persons or organizations
performing business or legal services in connection with my application, claim or as may be lawfully permitted or required, or as I may fully authorize. I
understand that any information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be
protected by federal regulations governing privacy (such as the HIPAA Privacy Rule). By my signature below, I authorize The Guardian Life
Insurance Company of America or its reinsurers to make a brief report of my protected health information to MIB, Inc.
I know that I may revoke this authorization in writing, at any time, by sending a written request for revocation to the Guardian Corporate Secretary at 7
Hanover Square, New York, NY 10004-2616. I understand that a revocation is not effective to the extent that the Company and/or any of the entities
listed above has already relied on this authorization, or to the extent that the Company has a legal right to contest a claim under an insurance policy or
to contest the policy itself.
I know that I may request and receive a copy of this authorization.
Please retain a copy for your records and submit this form to Guardian
EOI2012-NY-R
GG-016698-NY (11/14)
Page 4 of 6
I know that I may revoke this authorization in writing, at any time, by sending a written request for revocation to the Guardian Corporate Secretary at
7 Hanover Square, New York, NY 10004-2616. I understand that a revocation is not effective to the extent that the Company and/or any of the entities
listed above has already relied on this authorization, or to the extent that the Company has a legal right to contest a claim under an insurance policy or
to contest the policy itself.
I know that I may request and receive a copy of this authorization.
I agree that a photocopy of this authorization will be as valid as the original. I agree that this authorization will be valid for twenty four months from the
date shown below.
By my signature below,
1. I agree with all of the terms, conditions, statements, and representations stated above in Part I. Representations of the Proposed Insured; and
2. I agree and consent to the Company obtaining and disclosing the information as stated above in Part II. Authorization to Obtain Information (Medical
Records and Other Information) and with all other terms and conditions stated therein.
Any person who with intent to defraud any insurance company or other person files an application for insurance or statements of claim containing any
materially, false information, or conceals for purpose of misleading information concerning any fact material hereto, commits a fraudulent insurance act,
which is a crime, and may also be subject to civil penalties, or denial of insurance benefits. (Does not apply to Life Insurance.)
The state in which you reside may have a specific state fraud warning. Please refer to the Fraud Warning Statements page below.
The laws of New York require the following statement appear: 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. (Does not apply to
Life Insurance.)
_________________________________________________________________ ______________________
Signature of Employee Date
_________________________________________________________________ ______________________
Signature of Spouse Date
Please retain a copy for your records and submit this form to Guardian
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Page 5 of 6
Insurance Information Practices Please read and detach for your records
Thank you for choosing The Guardian Life Insurance Company of America (“Guardian”). This notice is given to you at the time you apply for life or
disability insurance to tell you about the kinds of information we may obtain in connection with your application. We will treat all personal information
about you as confidential, except as authorized by you, or as required by law. You have a right of access and correction with respect to this information.
If you wish a more detailed explanation of our information practices, please send your written request to: The Privacy Office, The Guardian Life
Insurance Company of America, 7 Hanover Square, New York, NY 10004-4025.
MIB, Inc. Pre-Notice: Information regarding your insurability will be treated as confidential. Guardian, or its reinsurers may, however, make a brief
report thereon to MIB, Inc., a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its
Members. If you apply to another MIB, Inc. member company for life, health or disability insurance coverage, or a claim for benefits is submitted to such
a company, MIB, Inc., upon request, will supply such company with the information about you in its file.
Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any information it may have in your file. Please contact MIB, Inc., at 866 692-
6901 (TTY 866 346-3642). If you question the accuracy of the information in your MIB, Inc. file, you may contact MIB, Inc., and seek a correction in
accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB, Inc., information office is 50 Braintree Hill Park,
Suite 400, Braintree MA 02184-8734.
Guardian, or its reinsurers, may also release information in its file to other insurance companies to whom you may apply for life, health, or disability
insurance, or to whom a claim for benefits may be submitted.
Medical Records: We may request information from health care providers or others who have records of your medical history, mental or physical
condition, or treatment. Only qualified members of Guardian’s staff will have access to your medical file to evaluate your eligibility for insurance or to
service your claim for benefits under a policy. Your authorization will govern our request for information and any later disclosure of that information.
Please retain a copy for your records and submit this form to Guardian
EOI2012-NY-R
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Page 6 of 6
Fraud Warning Statements
The laws of several states require the following statements to appear on the evidence of insurability form:
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a
false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
California: For your protection California law requires the following to appear on this form: The falsity of any statement in the application
shall not bar the right to recovery under the policy unless such false statement was made with actual intent to deceive or unless it
materially affected either the acceptance of the risk or the hazard assumed by the insurer.
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.
Connecticut, Iowa, Kansas, Nebraska, Oregon, and Vermont: Any person who knowingly, and with intent to defraud any insurance company or
other person, files an application of insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto, may be guilty of a fraudulent insurance act, which may be a crime, and may also be
subject to civil penalties.
Delaware, Indiana and Oklahoma: WARNING: Any person who knowingly, and with the intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia: 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.
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 a 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.
Louisiana and Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be
subject to fines and confinements in state prison.
New Mexico: Any person who knowingly presents a false or fraudulent claim for payment or a loss or benefit 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 or denial of insurance benefits.
Maine, Tennessee, Virginia and 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 benefit.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any
false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in
N.H. Rev. Stat. Ann. § 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil
penalties.
Ohio: Any person who with intent to defraud or knowing that he/she 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 and willfully presents a false or fraudulent claim for payment of a loss or benefit or 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.
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