To see detailed information on our plan, click
here
Term insurance is one of the
most cost effective ways to get the coverage you need.
At Term insurance plans has a death benefit that you pick, as well as
a period of time the
insurance is in force with the premium that is "level" for
the duration that
you select!!
To see rates for the planclick
here (Rates are quoted, per month)
I have reviewed the Term Rates and am interested in pre-enrolling in a plan
with
a face amount of (Death Benefit $)
I would like my term insurance plan to have a "term" of
( The "term" of a life
insurance plan is how long the plan will be in force at the same rate/premium
as when you originally purchased the plan. For
example you purchase a plan with a "20" year term. This plan will
remain in force (assuming all premium payments are made) for twenty years with
no increase in the premium. )
My estimated monthly premium for the life plan would
be $
(Select your annual income , to see
what monthly benefit would be adequate)
There are two disability plans to choose from :
Plan I am interested in (If you are between the
ages of 17 to 49 these plans below are for you)
1) This disability plan below pays from
the 1st day of an disability caused by a covered accident,
and from the 14th day of a disability caused by a covered illness.
This plan below pays up to "6 months" !
2) This disability plan below pays from
the 1st day of an disability caused by a covered accident,
and from the 14th day of a disability caused by a covered illness.
This plan below pays up to " 12 months" !
Plan I am interested in (If you are between the
ages of 50 to 64 these plans below are for you)
There are two plans to choose from :
1) This disability plan below pays from
the 1st day of an disability caused by a covered accident,
and from the 14th day of a disability caused by a covered illness.
This plan below pays up to "6 months" !
2) This disability plan below pays from
the 1st day of an disability caused by a covered accident,
and from the 14th day of a disability caused by a covered illness.
This plan below pays up to " 12 months" !
My estimated monthly premium for the Critical Illness
plan would be $
Your company may offer a Medical Reimbursement and Dependent Child
Care.
To understand more about these plans
Click
here to get information about Medical Reimbursement
Click
here to get information about Dependent Care
If you would like to enroll in either of these plans after reading about
them you can select below the amount "per year" you would like to
put into the plan:
Medical Reimbursement Annual Contribution Amount $
Dependent Care Annual Contribution Amount
$
Pre-Enrollment Information
Your Name
Your Employer
Do you currently have voluntary insurance coverage with us ?
Yes I already have coverage
No I do not currently have voluntary insurance coverage.
If yes, what type do you have:
If Spouse is to be covered please provide name
Spouse date of birth
Your job title
Your email address
(We need an accurate email so we can email you follow up information per you
request so please enter your email accurately (for example susan@aol.com)
Your date of birth
Your current age
(Age you will be 45 days from now)
Social Security Number
Your home phone number
Your Work Phone Number
Your mobile phone number
Street Address City
State Zip Code
The number of paychecks you receive a year
Comments/Questions
(Waiver) I have reviewed the Voluntary Benefit
Options and have decided to "Waive"
all benefits at this time
Here are the health questions to answer to apply for these
coverages:
If you would like to
pre-enroll in the Disability Plan, or the Medical Supplement Plan,
please answer these 4 questions below:
1) Have you or any proposed insured been diagnosed with or received
treatment for acquired immune deficiency syndrome (AIDS) or AIDS-related
complex (ARS)? Yes
No
2) Within the past 12 months, other than colds , flu or normal pregnancy,
have you taken time off from work or taken vacation for 10 or more consecutive
days due to an illness or injury, including back, knee, joint or muscular
disorder? Yes
No
3) Within the past 12 months have you
received medical advice or sought treatment (including medication) for: Heart
Attack, Heart Surgery, Congestive Heart Failure, Stroke, Transient Ischemic
Attack, Blood Pressure Reading of 160/100 or above ,Kidney Disorder except Stones, Insulin
Dependent Diabetes, Diabetes diagnosed prior to age 40, Cancer other than Skin
Cancer, Hepatitus B or C,Cirrhosis, Hodkins Disease, Leukemia. Yes
No
4) What is your annual base income ?
(Income without overtime)
If you would like to
pre-enroll in the Cancer Plan, please answer this question:
4) Have you or anyone to be covered, been
diagnosed with or treated for Cancer of any type? Yes
No
If you are covering dependents on the Medical Insurance Supplement
plan please answer this question:
5) Within the past 12 months has any dependent been hospitalized for
respitory disorders, including asthma, cystic fibrosis, diabetes, heart
condition, cancer (other than skin cancer, or seizures?Yes
No
If you would like to
pre-enroll in the Term Life Plan, and or the Critical Illness plan
please answer these questions in
addition to "all " questions above.
6) Within the past 12 months, has the applicant used any tobacco products
(cigarettes, cigars, snuff/dip/chew/pipe) and/or nicotine delivery systems?
Yes No
7) In the past 12 months, has the applicant been diagnosed with or treated
for renal failure? Yes
No
8) In the past 12 months has the applicant been diagnosed with or
treated for chronic lung disease,
schizophrenia or manic depressive disorder?
Yes No
9) In the past 12 months has the applicant been diagnosed with or
treated for drug and/or alcohol abuse or convicted for driving under the
influence of drugs and/or alcohol (DUI or DWI)? Yes
No
Details of any "yes" answers here below:
(Once you hit "submit" you will receive a confirmation that your
information has been sent to us; we will then follow up with you; please make
sure to provide an accurate email address as well as accurate phone
numbers. Thank you. )
RATE/PLAN DESCRIPTION DISCLAIMER: RATES/PREMIUMS/PLAN
PROVISIONS REFERENCEDWERE INTENDED
TO BE ACCURATE, BUT THE ISSUED POLICY WILL BETHE CONTRACTUAL RATES; ONCE POLICY IS ISSUED (Contingent on underwriting
approval) AND RECEIVED BY APPLICANT,
APPLICANT WILL HAVE A “FREE-LOOK”PROVISION
TO EXAMINE BOTH THEPOLICY AND THEPREMIUM . APPLICANT CAN THEN DECIDE TO KEEPPOLICY OR EXERCISE“FREE-LOOK”
PROVISION AND RETURN POLICY FOR A FULL REFUND (SEE “FREE LOOK “ PROVISION
STATED ON POLICY, ONCE ISSUED. (This "Free-Look" provision will be
wrttien on front of Policy; if you would like to an example of a
"free-look" provision, click
here )
