peo enrollment forms - paycheck connection

PEO Benefits Enrollment Checklist

Employee Name: _______________________________________________

Client Name: __________________________________________________

Benefits Eligibility Date: ______________________

I am a part-time employee, regularly working less than 15 hours per week and am not eligible

for benefits at this time.

I am a full-time employee, regularly working at least 15 hours per week. Please enroll me in

the following benefits. I have completed the appropriate benefit enrollment forms.

NOChanges

YESChanges

ADDBenefit

DROPBenefit

Cafeteria Section 125 – Flexible Spending Account Cafeteria Section 125 – Dependent Care Assistance Ternian –Term Life TeleMedicine/HealthiestYou Colonial Life – Dental Plan VSP – Vision Plan Life Flight – Critical Care Transport Heritage Health Aflac – PEO Large Group Alfac – Term Life LegalShield Identity Theft Shield

**If ADDING or DROPPING a benefit, you must fill out a waiver on the appropriate

benefit form**

________ I understand that if I do not enroll at this time, I must wait until open enrollment to elect

coverage unless I experience a qualifying event during the year.

________ I understand that if I have not completed a Salary Redirection Agreement waiving pre-tax

benefits, my medical, dental, and vision deductions (if any) will be deducted from my paycheck

on a pre-tax basis.

________ I understand that a change in family status must occur for me to make changes to my medical,

dental, and/or vision coverage.

Signature: ______________________________________________ Date: _______________________

(Fill out the appropriate forms attached and turn them in to your supervisor as instructed)

HEALTH FSA ELECTION FORM _______________________________________________________________________________ (Please Print)

1. PERSONAL DATA PLAN YEAR ______________ Effective Date______________

Name _____________________________________________ Home Phone#______________

Address ______________________________________________________________________ (Street) (Apt.#) (City) (State) (Zip)

Soc. Sec. #____________________ Date of Birth______________ Date of Hire__________

Email Address _________________________________________________________________

DEPENDENT INFORMATION (Must List ALL Dependents Affected by Enrollment) Add

Change Last Name First Name Relationship M/F SS# Date of

Birth

Employee Self

Dependent

Dependent

Dependent

Dependent

PAYROLL SCHEDULE Weekly Bi-Weekly Semi-Monthly Monthly ______________________________________________________________________________________

2. FLEXIBLE SPENDING ACCOUNT CONTRIBUTIONS

HEALTH FLEXIBLE SPENDING ACCOUNT YES NO $_________/Per Pay $___________/Annually _______________________________________________________________________________________________

3. AUTHORIZATION AND ACKNOWLEDGEMENT

I understand that I cannot revoke or change this election during the year unless there is a qualifying

“Status Change”. The requested election change must be consistent and in line with the qualifying

event. I may then revoke my prior election and sign a new Agreement if such a change occurs.

I understand that I must submit a claim and appropriate documentation (e.g. explanation of

benefits, itemized bill) for out-of-pocket Medical, Dental, Vision expenses before I can be reimbursed.

I understand that the plan provisions will require that all Health FSA participants who have a positive

balance (taking into account all claims submitted prior to termination) at the time of terminating

employment will be provided with information regarding their COBRA options, if applicable (see your

Summary Plan Description regarding COBRA qualifications). If the continuation for the Health FSA is

not elected, I realize that I will not be reimbursed for any expenses incurred after the date

employment terminates.

I herby elect to participate in a Flexible Spending Account as indicated on this form. I authorize

PayCheck Connection, LLC to make pretax deductions from my salary on the payroll schedule I’ve

elected above. I understand that to stop such deduction, I must notify PayCheck Connection, LLC

Benefits office in writing with my request, and revoke this authorization.

Any unused dollars remaining in your Flexible Spending Account at the end of the year will be

forfeited. Expenses/claims must be incurred during the time that you participate in the plan in order

to be eligible for reimbursement.

SIGNATURE _____________________________________________ DATE ______________________

DEPENDENT CARE ASSISTANCE PLAN ELECTION FORM _______________________________________________________________________________ (Please Print)

1. PERSONAL DATA PLAN YEAR ______________ Effective Date______________

Name _____________________________________________ Home Phone#______________

Address ______________________________________________________________________ (Street) (Apt.#) (City) (State) (Zip)

Soc. Sec. #____________________ Date of Birth______________ Date of Hire__________

Email Address _________________________________________________________________

DEPENDENT INFORMATION (Must List ALL Dependents Affected by Enrollment) Add

Change Last Name First Name Relationship M/F SS# Date of

Birth

Dependent

Dependent

Dependent

Dependent

Dependent

PAYROLL SCHEDULE Weekly Bi-Weekly Semi-Monthly Monthly ______________________________________________________________________________________

2. FLEXIBLE SPENDING ACCOUNT CONTRIBUTIONS

HEALTH FLEXIBLE SPENDING ACCOUNT YES NO $_________/Per Pay $___________/Annually _______________________________________________________________________________________________

3. AUTHORIZATION AND ACKNOWLEDGEMENT

I understand that I cannot revoke or change this election during the year unless there is a qualifying

“Status Change”. The requested election change must be consistent and in line with the qualifying

event. I may then revoke my prior election and sign a new Agreement if such a change occurs.

I understand that I must submit a claim and appropriate documentation for out-of-pocket

Dependent Care Expenses before I can be reimbursed.

I understand that the plan provisions will require that all DCAP FSA participants who have a positive

balance (taking into account all claims submitted prior to termination) at the time of terminating

employment will be provided with information regarding their COBRA options, if applicable (see your

Summary Plan Description regarding COBRA qualifications). If the continuation for the DCAP FSA is

not elected, I realize that I will not be reimbursed for any expenses incurred after the date

employment terminates.

I herby elect to participate in a Flexible Spending Account as indicated on this form. I authorize

PayCheck Connection, LLC to make pretax deductions from my salary on the payroll schedule I’ve

elected above. I understand that to stop such deduction, I must notify PayCheck Connection, LLC

Benefits office in writing with my request, and revoke this authorization.

Any unused dollars remaining in your DCAP Spending Account at the end of the year will be

forfeited. Expenses/claims must be incurred during the time that you participate in the plan in order

to be eligible for reimbursement.

SIGNATURE _____________________________________________ DATE ______________________

Enrollment Form for Group InsuranceAXIS Global Accident and Health Insurance

Step 1: Select Your Enrollment Method (Choose one only.)

1. WEB: http://paycheckconnection.myternian.com 2. PAPER: Turn in the form to your employer

YOUR GROUP NUMBER IS: 8999858

Search PHCS network providers at: www.myternian.com or call 1-866-750-7427(You DO NOT need to use these providers – they provide discounts should you choose to visit them. You can visit ANY licensed physician and present your insurance card – you may qualify for a discount. But regardless, you still have insurance coverage as outlined in this brochure.)

Step 2: Select the plan(s) that you want. DETAILS AND PRICING FOR EACH PLAN ON PREVIOUS PAGES.

Step 3: Select who you want to cover. CHECK ONLY ONE EVEN IF MULTIPLE PLANS ABOVE ARE SELECTED.

I want to cover myself only I want to cover myself and 1 dependent (spouse or child) I want to cover myself and my family

Step 4: Provide the information that we need in order to enroll you and/or your family members.

First Name M.I. Last Name Gender (M/F) Date of Birth

Social Security Number Hire Date

Street Address City State Zip Code

Email Address (REQUIRED for DoctorNavigator login access) Primary Phone # Home Work Cell

DEPENDENT INFORMATION (IF ANY): For more than 3 dependents attach additional sheet. Full Time Student? Yes No

Spouse/Child First Name M.I. Last Name Gender (M/F) Birth Date (mm/dd/yyyy)

Full Time Student? Yes No

Full Time Student? Yes No

BENEFICIARY INFORMATION: Person who will receive benefits in the case of your death. You will be the beneficiary for dependents.

First Name M.I. Last Name Gender (M/F) Relationship to You

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.

Employee’s Signature Date Signed

Declination Waiver: (check the box below if you are not enrolling in the plan; YOU ARE STILL REQUIRED TO SIGN AND DATE THE FORM):I choose not to enroll in the plans being offered by my employer. I understand that, if at a later date, I wish to enroll in this plan, I will not be able to do so until there is another open enrollment period.

I have read the AXIS Global Accident and Health Insurance Company enrollment brochure, including the exclusions and limitations, and accept the terms and conditions of the coverages outlined in it. I understand the fixed indemnity insurance plans are not considered creditable coverage under HIPAA and do not provide Major Medical or Comprehensive Medical coverage. I have read the enrollment brochure and understand my coverage is subject to the terms and conditions of the policy issued to my employer. I understand my coverage will go into effect on the date stated in the brochure only if I am in active service with my employer on that date. If I am not in active service on that date, my coverage will go into effect on the date I return to active service. If I have elected coverage for my dependents, their coverage will not go into effect prior to my effective date. I authorize my employer to deduct the required premium for the plan I have elected from my pay. If direct billing is offered, I authorize Ternian Insurance Group to charge the required premium for the plan I have elected from my credit or debit card. To the best of my knowledge and belief, all information I have provided is true and complete. I understand my information is protected by privacy laws and will be released only in accordance with these laws. The only people who have access to this information are employees of the Insurance Company who service my policy or claim and other third parties authorized by the Insurance Company. Information may be disclosed to those who have an insurance-related regulatory or legal need for the information. In other situations, the Insurance Company will ask me for written authorization to disclose information about me.

Group Term Life$10,000Plan $20,000 Plan

EE Only EE + DependentEE + Family

Phone: 877.303.7590 Fax: 877.303.7591

PO Box 1510; Hayden, ID 83838

TeleMedicine Through HealthiestYou

HealthiestYou is changing the way real people access healthcare!

For only $19.95/month.

□ Employee Only □ Employee + Family

Name Relationship Gender Date of BirthEmployee

Address:City, State, Zip: Phone:Email Address:

______________________________________

Signature

DentApp-ID 82736

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY PO BOX 1365, COLUMBIA, SC 29202

DENTAL INSURANCE APPLICATION FORM

New Coverage Upgrade Dependent Addition Existing Policy No. _________________________ Reinstatement Downgrade Rider Addition

EMPLOYEE SECTION Proposed Insured Name (First, MI, Last) Gender

M F

Birthdate (mm/dd/yyyy) Social Security No.

Home Address – Street City State Zip Code

Email Address Home Phone No. Business Phone No.

Date Employed Hrs. Worked/Wk Section/Dept. No. Job Title Employee ID/Payroll No.

Employer Name

Employer Address (Street-City-State-Zip)

SPOUSE/DEPENDENT SECTION (complete if applying for spouse and/or dependent coverage) Name (First, MI, Last) Gender Birthdate (mm/dd/yyyy) Relationship Social Security No.

M F

M F

MF

M F

MF

MF

MF

ELIGIBILITY SECTION 1. Are you actively working? If “No” you are not eligible for any coverage. Yes No

REPLACEMENT SECTION 2a. Will any dental insurance with this or any other company be replaced or changed if the coverage applied for is issued? If yes, complete required replacement form if applicable in your state and complete 2b. 2b. If replacing existing coverage, please indicate if existing coverage is Colonial Life & Accident Dental coverage or another carrier’s Dental coverage by checking the appropriate box. Colonial Life & Accident Insurance Company Other

Yes No

PLAN SECTION Type of Coverage Type of

Change Level of

Coverage Policy Plan Code

Vision Coverage (select Yes or No)

Orthodontia Coverage (select Yes or No)

Tax Status (P) pre-tax(A) after tax

Monthly Premium

Individual Individual &Spouse Individual &Children Individual &Family

Not Available

OTHER SECTION 3. Do you have any existing dental coverage that will remain in force? If yes, please provide company name.

_______________________________________________________________________Yes No

4. Are you Medicare eligible? Yes No 5. Has the Important Notice to Persons on Medicare and the Guide to Health Insurance for People with Medicare beenprovided?

Yes No

Sambedino, Inc 254 W. Hanley Ave; Coeur d'Alene, ID 83815

Not Available Plan 4

Plan 5

DentApp-ID 82736

AGREEMENT SECTION It has been explained and I understand that any coverage approved may be subject to waiting periods, exclusions and limitations as described in the policy.

I understand that this application will not be binding upon Colonial Life until both: 1) the policy is issued; and 2) the first premium is paid. Items 1 and 2 must occur while any conditions affecting insurability are the same as described above. I understand that any untrue statement or material misrepresentation may result in claim denial or rescission of coverage. If coverage is rescinded, Colonial’s only obligation will be to refund all premiums paid. I certify under penalties of perjury that the Social Security number shown on this form is my correct TAXPAYER IDENTIFICATION NUMBER.

I authorize my employer to make the necessary deductions from my salary or wages to pay the premium when my insurance becomes effective. I also understand that my payroll deduction amount will change if my coverage or premium changes.

Any person who knowingly and with the 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.

REQUEST FOR TRANSFER/CANCELLATION: In conjunction with my application for the coverage indicated, I hereby request cancellation of my Colonial Life Policy Number(s) _____________________. Transfer or cancellation of the base plan will also mean cancellation of all attached riders. If for any reason the coverage applied for above is not issued, this request for cancellation shall be null and void.

This policy provides dental and/or vision benefits only. Review your policy and any applicable riders carefully.

Signed at: City_________________________________ State ___________ Zip Code ___________ Date _____________________________ mm/dd/yyyy (x)___________________________________________________________________________________________________________________ Signature of Proposed Insured (if applicable)

AGENT SECTION

Agent’s Name (If Present): _____________________________________________________________________ (please print)

Do you have knowledge or reason to believe that the Proposed Insured is intending to replace any existing dental insurance? Yes No

I have explained to the Proposed Insured all exceptions and limitations pertaining to the coverage(s) applied for, including any pertaining to waiting periods and limitations, if applicable. I hereby certify that I know nothing affecting the insurability of the Proposed Insured, which is not fully set forth in this application. I have not made, nor agreed to make, any rebate of premium for insurance. I further certify that I am a licensed agent in the state where this application is being taken. Date___________________ (x)_____________________________________________ License No._________________ Code No.___________

mm/dd/yyyy Signature of Licensed Agent

Coeur d'Alene ID 83815

Carolyn Schultz

77425 776545

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G R O U P I N S U R A N C E

H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H5 T W SV ` M M )= M T J M Y B QO U I [\ YM 4 I [M B QO U M L 5 T W SV ` M Y B QO U I [\ YM 3 V T W I U ` > I T M

Rev. 319

GROUP MEMBERSHIP ENROLLMENT

PayCheck Connection, LLC

MEMBER ENROLLMENT INFORMATION

Name: Date of Birth:

Spouse/Domestic Partner: Date of Birth:

Mailing Address:

City: State: Zip:

Phone: Email Address:

Additional Eligible Household Members:

Includes any dependents claimed on your tax return and elderly or disabled family members living in the same household

Date of Birth Relationship

_____ I am an existing member. ID# (if known)___________________

Member’s Signature: _______________________________________________

GROUP DISCOUNT MEMBERSHIP:

Annual fee of $59 per year per household. Discount rate is valid with enrollment through an approved group only. Payment directly to Life Flight Network is not available. Complete Statement of Understanding is found on the reverse side of this form.

LIFE FLIGHT NETWORK FOUNDATION

P.O. Box 3841 • Portland, Oregon 97208-3841 Phone: (503) 678-4370

This form is valid through 11/30/2020. Contact your employer or group representative for an updated enrollment form if this form is expired. New member benefits take effect 72 hours after receipt of completed enrollment form and payment. Life Flight Network transports patients based on medical need, not membership status. Medicaid beneficiaries should not apply for membership. Life Flight Network operates under its own FAA Part 135 Air Carrier Certificate.

Rev. 319

STATEMENT OF UNDERSTANDING

By becoming a Life Flight Network Member, you agree to the terms stated below.

A Life Flight Network Membership relieves you from liability for out-of-pocket costs of emergent, medically necessary transports completed and billed by Life Flight Network. Your membership is not an insurance policy but secondary to insurance carriers and health care cost sharing programs. All available insurances will be billed first including health, auto, workers compensation and third-party insurance. Life Flight Network will accept payment from insurance carriers and other third party payers as payment in full.

Membership benefits are available for those eligible household members listed on the member record at the time of transport if the transport is an emergent, medically necessary transport to the closest, most appropriate facility, performed by Life Flight Network, its contracted agents, or reciprocal partners, subject to the reciprocal program’s rules.

Membership benefits are extended to the primary member, his/her spouse or domestic partner and dependents claimed on their income tax return. Dependents must be added to the member record within 30 days of birth or adoption. Elderly (age 65+) and disabled family members living in the same household are also covered. Life Flight Network may require documentation or other verification of membership eligibility.

Emergency medical transports are based on medical need, not membership status. Medical need can only be determined by a physician, EMS provider, hospital or another qualified third-party recognized by Medicare, and is in all cases subject to the final determination of the health insurance carrier, if any. Non-emergent transports are not eligible for Life Flight Network membership benefits.

Availability of service cannot be guaranteed due to weather conditions, maintenance, commitment to another transport, out-of-service equipment and other reasons.

New and lapsed membership benefits take effect 72 hours after receipt of a completed enrollment with payment.

Membership fees are non-refundable, non-transferable and are not tax-deductible. Life Flight Network may cease selling and servicing memberships should any governmental body, now or in the future, determine memberships can no longer be offered within their jurisdiction. No refunds will be made for any memberships already purchased.

I transfer directly to Life Flight Network my rights to insurance payments due to me for services provided by Life Flight Network. Such payments shall not exceed Life Flight Network’s regular charges. Denial of a claim by an insurance provider must be received by Life Flight Network in writing. Membership benefits do not extend to transports deemed not medically necessary or when insurers deny payments due to coordination of benefit issues. Per government regulations, individuals covered by Medicaid are not eligible for Life Flight Network membership and should not apply.

I specifically release and waive any and all rights, claims or causes of action against Life Flight Network and its employees and agents with respect to my Life Flight Network Membership.

The Membership Program may be canceled at any time for any reason, including financial feasibility and governmental regulation of such programs. Terms and conditions are subject to change. For current terms see www.lifeflight.org

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of 3 C01205ID

FOR HOME OFFICE USE ONLY

PLAN PLAN CODE ID NUMBER

Accident Critical Illness Hospital Indemnity Endorsement:

EFFECTIVE DATE:

FOR AGENT USE ONLY

Initial

Enrollment New Hire Re-Enrollment New Eligible Re-Submission

Deduction start date ________________________ Applicant Name (First, MI, Last)

Social Security # or ID # Gender Date of Birth

Street Address

City

State

ZIP

Group Policyholder Sambedino Inc. #6216

Class Occupation Location Date of Hire

E-mail address Hours Worked per Week Daytime Phone No.

Spouse's Name (if coverage is requested)

Spouse’s Gender Spouse’s Date of Birth

Beneficiary Name/Relationship (estate unless designated otherwise) Applicant Spouse

Are you actively at work? YES NO

Have you used tobacco products in the last 12 months? YES NO YES NO

LIST ALL ELIGIBLE CHILDREN FOR WHOM YOU ARE PROPOSING COVERAGE (FROM YOUNGEST TO OLDEST):

Name Gender Date of Birth Name Gender Date of Birth

GROUP ACCIDENT INSURANCE

New Coverage Change in Coverage Applicant Applicant & Spouse Applicant & Children Family Cost per pay period: Including any Riders $__________

GROUP CRITICAL ILLNESS INSURANCE Applicant Applicant and Spouse New Coverage Change in Coverage With Cancer: yes With Health Screening Benefit: yes Heart Event Rider Progressive Diseases Rider Specified Disease Rider Additional Benefits Rider

Applicant Face Amount: $ Applicant cost per pay period: $

Spouse Face Amount: $ Spouse cost per pay period: $

TOTAL cost per pay period: $

STATEMENT OF INSURABILITY

COMPLETE FOR GROUP CRITICAL ILLNESS INSURANCE AMOUNTS REQUESTED ABOVE GUARANTEE ISSUE AMOUNT

Applicant Spouse

CONTINENTAL AMERICAN

INSURANCE COMPANY

EMPLOYEE APPLICATION Please Mail: P.O. Box 84078

Columbus, GA 31993 800.433.3036

of 3 C01205ID

1 In the past 7 years, have you been treated or diagnosed by a medical professional for Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC)? YES NO YES NO

2 In the last 7 years, have you been treated for or diagnosed with cancer or any malignancy, including: carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or a malignant tumor? Cancer does not include basal cell or squamous cell carcinoma of the skin.

YES NO YES NO

3

In the past 7 years, have you been treated for, or diagnosed with, any of the following: a) Stroke, heart attack, heart condition, heart trouble (or any abnormality of the heart—including artery disease), diabetes, or any liver disorder; b) Kidney (renal) failure or end stage kidney (renal) disease; c) Organ transplant; d) Emphysema; or e) High blood pressure, resulting in your now taking 3 or more medications for treatment?

YES NO YES NO

4 In the past 7 years, have you received any advice, treatment, or consultation for: any disorder of the central nervous system, Parkinson’s disease, Alzheimer’s disease, dementia, senility, or organic brain syndrome?

YES NO YES NO

5 In the last 2 years, have you had a prolonged state of unconsciousness lasting more than 48 hours or that left you with a significant neurological disability? YES NO YES NO

6 In the past 7 years, have you received any advice, treatment or consultation for a diagnosis of amyotrophic lateral sclerosis (Lou Gehrig’s disease) or multiple sclerosis? YES NO YES NO

GROUP HOSPITAL INDEMNITY INSURANCE New Coverage Change in Coverage Applicant Applicant & Spouse Applicant & Children Family Base Plan (check one): Mid Treatment Category (check one): Mid Surgery Category – Inpatient and Outpatient (check one): Mid

Cost Per Pay Period Including any Riders: ____________________________

If NOT Guaranteed Issue, answer the following questions:

Applicant Spouse Children

1 In the last 7 years, have you been treated or diagnosed by a medical professional for Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC) or ever tested positive for antigens or antibodies to an “AIDS” virus?

YES NO YES NO YES NO

2 In the last 7 years, have you been treated for or diagnosed with cancer or any malignancy, including: carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or a malignant tumor? Cancer does not include basal cell or squamous cell carcinoma.


3

In the last 7 years, have you been treated for, or diagnosed with, any of the following: a) Stroke, heart attack, heart condition, heart trouble (or any abnormality of the heart—including artery disease), diabetes, or any liver disorder; b) Kidney (renal) failure or end stage kidney (renal) disease; c) Organ transplant; d) Emphysema; or e) High blood pressure, resulting in your now taking 3 or more medications for treatment?


4 In the last 5 years, have you sought advice or treatment for alcohol abuse, been arrested for driving under the influence of or while impaired by alcohol, or been arrested for or used illegal drugs or narcotics?


of 3 C01205ID

To the best of my knowledge and belief, the answers to the questions on this application are true and complete. They are offered to Continental American Insurance Company as the basis for any insurance issued.

Does this coverage replace any existing Aflac individual policy? YES NO If yes, please identify which product: Critical Illness Accident Hospital Indemnity Dental Disability

Does this coverage replace or change any existing insurance? YES NO If yes, provide carrier and policy number: _____________________________________________________________________________________________ If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy via direct bill. You should contact your insurance carrier for an explanation of your options for both continuation or cancellation of your existing coverage. Coverage will not become effective unless you are actively at work on the Certificate Effective Date. If you are not actively at work on that date, coverage will become effective on the date you return to an active work status. CERTIFICATION: I have read the completed Employee Application /Statement of Insurability and the statements and answers that pertain to me and my spouse and my children. I certify that these statements and answers are true and complete to the best of my knowledge and belief, and that the statements and answers will be used by the insurance company to determine insurability. I realize any false statement or misrepresentation in the Employee Application /Statement of Insurability may result in loss of coverage under the Certificate. I understand that no insurance will be in effect until my Employee Application /Statement of Insurability is approved and the necessary premium is paid. I understand and agree that the coverage that I am applying for may have a pre-existing condition exclusion. I authorize the Group Policyholder to deduct the appropriate dollar amount from my earnings each pay period to pay Continental American Insurance Company the required premium for my insurance. I certify that I am actively at work. I certify that my spouse is not currently disabled or unable to work. I certify that I have accurately disclosed my and my spouse’s usage of tobacco products in the last 12 months. I certify, by signing below, that I am covered by a major medical policy or other coverage that satisfies the minimum essential coverage under the Affordable Care Act. A person is guilty of insurance fraud if he intends to defraud an insurer or if he knowingly facilitates a fraud against an insurer. Fraudulent activities include submitting an Application or filing a claim that contains any false or deceptive statement.

The policy provides limited benefits. Review your policy carefully. Date____________ Signature of Applicant___________________________________________ Date____________ Signature of Agent______________________________________________ Agent’s Printed Name____________________________________________________________ Agent No.___________________ State of Enrollment_________

This form is not complete unless signed and dated as indicated.

CAI9111

FOR HOME OFFICE USE ONLY

PLAN PLAN CODE ID NUMBER

Term Life

Endorsement:

EFFECTIVE DATE: Applicant Name/Owner (First, MI, Last)

S.S.N./ ID Number Gender Date of

Birth

Street Address

City

State

Zip

Employer

Sambedino Inc. #6216

Job Class Location Date of Hire

Hours Worked Daytime Phone No. ( )

Beneficiary Name / Relationship

Spouse's Name (if coverage is requested) Gender Spouse Date of Birth Spouse’s Beneficiary/Relationship

Employee Spouse

Are you actively at work? YES NO

Have you used tobacco products in the last 12 months? YES NO YES NO

Are you now hospitalized or unable to perform your normal duties and activities?

YES NO

List all eligible children for whom you are proposing coverage (from Youngest to Oldest):

Name Gender Date of Birth Name Gender Date of Birth

TTEERRMM LLIIFFEE BBaassee PPllaann 55 yyeeaarr,, 1100 yyeeaarr

Coverage: Employee Face Amount:____________ Premium:___________

Spouse Face Amount:____________ Premium:___________

Children Face Amount:____________ Premium:___________

OOppttiioonnaall BBeenneeffiitt

SSeeccttiioonn II -- CCoommpplleettee ffoorr MMooddiiffiieedd GGuuaarraanntteeee IIssssuuee

Applicant Spouse Children

1 Have you ever been treated for or diagnosed by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS) or “AIDS” Related Complex (ARC) or ever tested positive for antigens or antibodies to an “AIDS” virus?


2 In the last twelve (12) months, have you missed more than five (5) consecutive days of work due to illness or injury other than pregnancy, flu, strained or sprained muscle or fractured limb?


CONTINENTAL AMERICAN

INSURANCE COMPANY

ENROLLMENT FORM Please Mail: Post Office Box 84078

Columbus, GA 31993 (800) 433-3036

This application is not complete unless signed and dated on the back

CAI9111

SSeeccttiioonn IIII –– CCoommpplleettee ffoorr SSiimmpplliiffiieedd IIssssuuee Applicant Spouse Children

3 In the last 7 years have you been treated for or diagnosed with cancer or any malignancy, which includes carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or malignant tumor? Cancer does not include basal cell or squamous cell carcinoma.


4 Have you ever been treated for or diagnosed with a) a stroke, a heart attack, a heart condition, heart trouble, or any abnormality of the heart (including artery disease), diabetes, or any liver disorder; b) kidney (renal) failure or end stage kidney (renal) disease; c) organ transplant; d) emphysema or e) now taking 3 or more medications for high blood pressure?


5 Have you ever sought advice or treatment for alcohol abuse, been arrested for driving under the influence of or while impaired by alcohol, or been arrested for or used illegal drugs or narcotics?


If you answered Yes to any question for Child Coverage, indicate name of Child/Children

To the best of my knowledge and belief, the answers to the questions on this application are true and complete. They are offered to Continental American Insurance Company as the basis for any insurance issued.

Does this coverage replace or change any existing insurance? YES NO

If “Yes,” provide carrier and policy number:___________________________________________

CERTIFICATION: I have read the completed application and I realize any false statement or misrepresentation in the application may result in loss of coverage under the certificate. I understand that no insurance will be in effect until my application is approved and the necessary premium is paid.

Coverage will not become effective unless you are actively at work on the date of the enrollment and the effective date of coverage.

I authorize my employer to deduct the appropriate dollar amount from my earnings and to deduct and pay Continental American Insurance Company the premium required thereafter each pay period for my insurance. Deduction start date________________________

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. Date____________ Signature of Applicant _________________________________________ State of Enrollment _________ Date____________ Signature of Agent ____________________________________________ Agent #________________

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