application for group critical illness insurance...
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APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability
Unum Life Insurance Company of America (“Unum”) 2211CongressStreet•Portland,Maine04122 Application Type: NewlyEligible LateApplicant ReplaceExistingUnumCoverage ChangetoExistingCoverage Rehire SECTION 1: Employee (Applicant) Information – Always Complete
EmployeeName(First,Middle,Last) SocialSecurityNumber
HomeAddress(Street/POBox) Gender F MCity DateofBirth(mm/dd/yyyy)
State ZipCode HomePhone#
EmailAddress EmployeeID/Payroll#
EmployerName CustomerNumber DateofHire(mm/dd/yyyy)
St/POBox Occupation
City State ZipCode WorkPhone#
AreyouActivelyatWork? ScheduledNumberofWorkHours/week Yes No SECTION 2: Spouse Information – Complete Only if applying for Spouse Coverage
Name(First,Middle,Last) SocialSecurityNumber
Gender DoestheSpouseliveintheU.S.? Yes No DateofBirth(mm/dd/yyyy) F M If“No,”isyourSpouseaU.S.Citizen? Yes No
SECTION 3: Coverage Information – Complete for Employee (Applicant) and for Spouse (if applicable)
Employee Spouse (Applicant)
1. Haveyouoryourspouse(ifapplying)usedanytobaccoproducts(such ascigarettes,cigars,snuff,dip,cheworpipe)oranynicotinedelivery systeminthepast12months?.................................................................................. Yes No Yes No 2. WillcoverageappliedforreplaceormodifyanyexistingUnuminsurance coverage?................................................................................................................. Yes No Yes No If“Yes,”providedetailsbelow:
Insured’sName PolicyNumber
AE-1087-TN 1
AE-1087-TN 2
EmployeeName:________________________________________ EmployeeSSN:___________________________(Applicant) (Applicant)
SECTION 3: Coverage Information (continued)
3. Coverage Type Coverage Amount Cost Per Pay Period
a. GroupCriticalIllnessInsurance Employee $__________ Employee $__________ CriticalIllness Spouse $__________ Spouse $__________ or CriticalIllnesswithCancerb. WellnessBenefit $__________TotalCostPerPayPeriod............................................................................................................................... $__________
SECTION 4: Tier I Medical Profile – Complete as required for all underwritten coverage
Employee Spouse (Applicant) 1. Currentheightandweight ___ft.___in. ___ft.___in. ____lbs. ____lbs.
2. Haveyou(applicant)oryourspouse(ifapplying)testedpositivefortheHuman ImmunodeficiencyVirus(HIV)oritsantibodies,orbeendiagnosedwithorreceived treatmentforAcquiredImmuneDeficiencySyndrome(AIDS)?................................... Yes No Yes No
3. Inthepast10years,haveyouoryourspouse(ifapplying)receivedmedicaladvice, soughttreatment,includingmedication,orbeenhospitalizedforanyofthefollowing: Yes No Yes No
– Atrialfibrillation,angina,heartattack,coronaryarterydisease,heartsurgery, congestiveheartfailureorcardiomyopathy – ChronicObstructivePulmonaryDisease(COPD)oremphysema – CirrhosisoftheliverorHepatitisBorC – Diabetes(exceptgestationalordietcontrolled) – Glaucoma,retinitispigmentosaormaculardegeneration – Highbloodpressuretreatedwith3ormoremedications – Kidneydisease(excludingkidneystones)orfailure – Majororganfailure(liver,heart,lungorpancreas) – Stroke/TransientIschemicAttack(TIA)
4. Respondonlyifapplyingforcancercoverage: Inthepast10years,haveyouoryourspouse(ifapplying)beendiagnosed,received medicaladvice,soughttreatment,includingmedication,orbeenhospitalizedfor cancerormalignancyofanykind(includingcarcinomainsituandmelanoma), excludingbasalandsquamouscellcarcinoma?.......................................................... Yes No Yes No
EmployeeName:________________________________________ EmployeeSSN:___________________________(Applicant) (Applicant)
SECTION 5: Tier II Medical Profile – Complete if additional underwriting is required
Employee (Applicant)
1. Tothebestofyourknowledgeandbelief,haveanytwoofyournaturalparentsornatural siblings(sistersorbrothers)beendiagnosedwiththesamediseasebeforeage60based onthefollowinglist: a. Heartattackordisease,stroke,kidneydiseaseordiabetes................................................. Yes No
b. Respondonlyifapplyingforcancercoverage: – Cancer(excludingbasalcellcarcinomaandsquamouscellcarcinoma)....................... Yes No
2. Haveyoueverreceivedmedicaladvice,soughttreatment,includingmedication,orbeen hospitalizedforanyofthefollowing: a. – ChronicObstructivePulmonaryDisease(COPD),emphysemaorchroniclungdisease – CirrhosisoftheliverorHepatitisBorC – Diabetes(exceptgestational) – Heartattack,coronaryarterydisease,angina,orsurgeryontheheartorheartvalve(s) – Kidneydiseaseorfailure(excludingkidneystones,sponge,horseshoeorectopickidney andkidneyremovalduetotrauma) – Majororganfailure(liver,heart,lungorpancreas) – Peripheralvasculardisease – Stroke/TransientIschemicAttack(TIA).......................................................................... Yes No
b. Respondonlyifapplyingforcancercoverage: – Cancer(excludingbasalcellcarcinomaandsquamouscellcarcinoma)....................... Yes No
AE-1087-TN 3
EmployeeName:________________________________________ EmployeeSSN:___________________________(Applicant) (Applicant)
SECTION 6: Employee (Applicant) Statements
Iunderstandtheeffectivedateofcoverageissuedbasedonthisapplicationissubjecttotheapplicationbeingacceptableundertherules,limitsandstandardsofUnumLifeInsuranceCompanyofAmerica(hereafterUnum)andtheinsuranceis,orwouldhavebeen,issuedasappliedfor(orifnotissuedasappliedfor,thenasmodified).Theeffectivedateofapprovedcoveragewillbedeterminedassetforthinthecertificateofcoverageprovidedtome.IfIpaypartorallofthecostofmycoverage,theeffectivedatewillnotbeearlierthanthefirstofthemonthinwhichpayrolldeductionsbegin. Iauthorizemyemployertodeductthepremiumsforthisinsurancefrommyearnings(unlessthecoverageforwhichIamapplyingallowsforalternatemethodstopayinsurancepremiums). Allstatementsandanswersprovidedonthisapplicationaretrueandcomplete,andaregiventoobtaininsurance.
CAUTION:Unumwillrelyontheinformationprovidedinordertoevaluatethisapplication.Iftheanswersprovidedareincorrectoruntrue,Unummaydenybenefitsorrescindinsurance.
Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
Employee(Applicant)Signature Date(mm/dd/yyyy)
UnumisaregisteredtrademarkandmarketingbrandofUnumGroupanditsinsuringsubsidiaries.TheinsuranceproductisunderwrittenbyUnumLifeInsuranceCompanyofAmerica.
AE-1087-TN 4
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