Form Lrs-8209-1088 - Preliminary Application For Group Insurance Form printable pdf download

Reliance Standard Life

PRELIMINARY APPLICATION FOR GROUP INSURANCE

Insurance Company

1. Prospective Policyholder:__________________________________________________________________________

(Exact Legal Name)

2. Federal Employer Identification Number:_____________________________________________________________

3. Complete address: _____________________________________________________________________________

(Street Address)

(City and State)

(County)

(Zip Code)

Executive Correspondent_______________________Title_____________________ Phone____________________

Routine Correspondent_________________________Title_____________________Phone____________________

Mailing Address (If different)______________________________________________________________________

4. Nature of business: (If Association: purpose, when formed) _____________________________________________

5. The prospective policyholder is a ___ corporation, ___ partnership, ___ proprietorship, ___ union,

__association, ___other (specify) __________________________________________________________________

6. INDICATE AFFILIATES OR SUBSIDIARIES TO BE COVERED, IF ANY:

(Include divisions only if all are not to be included)

No. of Employees by Coverage

Name and Location

Nature of

Relationship

Business

Life

AD&D

WI LTD VAR STOP Other

________________________________________________________________________LOSS_____________________

7. POLICY TO BE ISSUED IN THE STATE OF :____

8. Requested Effective Date: __________________________

(If other than state of Applicant’s main office, explain in REMARKS)

(Month)

(Day)

(Year)

9. COVERAGES APPLIED FOR: __Life, __AD&D, __WI, __LTD, __VAR, __STOP LOSS, __Other_________

10. Is any group insurance now in force or currently being applied for on the Proposed Insureds?____yes ____no

If yes, (A) Indicate in Remarks: name of carrier; type of coverage; effective date; brief benefit description;

eligibility; etc.

(B) Provide prior experience, including premiums and incurred claims(or paid claims and claim reserves at

start and end of period.)

11. Is it proposed to terminate or change any existing group insurance coverage? ___yes ___no

If yes, indicate in REMARKS: name of carrier; type of coverage, and date of termination, or date and type of change.

12. Are all Proposed Insureds actively at work? ___yes ___no If not, please list the following for employees not

actively at work:

NAME

DATE OF BIRTH

LAST DAY WORKED

FACE AMOUNT

REASON FOR ABSENCE

REMARKS:

This Preliminary Application is subject to the acceptance and approval in writing by Reliance Standard Life Insurance

Company at the Administrative Offices in Philadelphia, Pennsylvania; and nothing contained herein shall be binding upon

said Company until this Preliminary Application is so approved. $_____has been paid herewith. It will be applied toward

the first premium due on the policy or policies if any be issued. Such issuance is subject to the: terms; conditions;

limitations; and exceptions of the policy or policies if any be issued.

Name of Agent or Broker of Record (print or type)

by______________________________________

_______________________________________ _________%

)

(authorized signature

_______________________________________ _________%

______________________________________

)

(title or position with Applicant

Print or type name of Broker’s firm, if applicable

Dated at _________________________________

__________________________________________________

Date_____________________________________

Group

by________________________________________________

Agency____________ Office_________________

(authorized signature)

(Title)

LRS-8209-1088

Form Lrs-8209-1088 - Preliminary Application For Group Insurance Form

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