Enrollment Form For Group Insurance (Page 2 of 2) in pdf

Enrollment Form For Group Insurance Page 2

E. Request for Coverages

This coverage has been offered to me and after careful consideration of the benefits, I have decided to:

! ! ! ! REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life

Insurance Company. I hereby apply for group insurance, for which I am eligible or may become eligible. If contributions are required, I

authorize my employer to deduct premiums from my salary.

! ! ! ! NOT ENROLL myself in the Program. I understand that if I apply for coverage at a later date, and if a physical examination or further

medical information is required, it will be at my own expense.

! ! ! ! NOT ENROLL my dependents in the Program. I understand that if I apply for coverage for my dependents at a later date, and if a

physical examination or further medical information is required, it will be at my own expense.

NOTICE: 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 OR 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.

The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln

National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective

date will apply if the employee is not actively at work, or a dependent is in a period of limited activity on the date insurance would otherwise

take effect.

Employee Full Name:

Employee Signature:

Date:

GLAD 4 11/00

Enrollment Form For Group Insurance Page 2