Flex Shield Questionnaire Template (Page 2 of 2) in pdf

ADMINISTRATIVE

Will this insurance replace similar coverage?

Yes (Show the name of carrier and dates of coverage)

Carrier _________________________________________ Effective Date _____/_____/_____ Termination Date _____/_____/_____

ENROLLMENT AND BILLING INFORMATION

Paper

Web

Phone

Laptop (face-to-face)

Billing Delivery Method

Web (preferred)

Paper

Automated (contact us for details)

Billing Option

Payroll Frequency Equals Remittance Frequency

Please select one:

Bill 52 times per year/Pay 52 times per year

26 bill/12 remit

24 bill/12 remit

12 bill/12 remit

Payroll Frequency Does Not Equal Remittance Frequency

Please select one:

Bill 52 times per year/Pay 12 times per year

26 bill/26 remit

24 bill/24 remit

12 bill/12 remit

Bill Monthly On The First Of The Month

REFUNDS

Credit Next Bill

Check to Employer (post-tax plans only)

MEMBERSHIP MAINTENANCE

Manual

Tape

Electronic Transfer (For Tape or Electronic Transfer Attach Format or indicate IS Contact Person below)

Please Provide an Eligibility and Billing Service Contact Person

Eligibility Contact ______________________________________________________ Title _________________________________________________

Phone Number _____._____.___________ Fax Number _____._____.__________ E-Mail ____________________________________________________________

Billing Contact _______________________________________________________________________ Title ______________________________________________________________

Phone Number _____._____.___________ Fax Number _____._____.__________ E-Mail ____________________________________________________________

Deliver Administration Package to

Group

Broker

AIG Representative

THE EMPLOYER UNDERSTANDS AND AGREES

• The requested insurance will not become effective unless National Union Fire Insurance Company of Pittsburgh, Pa.,

or AIG Life Insurance Company receives and approves the enrollment form.

• Being actively at work is a requirement for coverage.

• No waiver or change will bind National Union Fire Insurance Company of Pittsburgh, Pa., or AIG Life Insurance Company

unless signed by our officer.

Signature _______________________________________________________________________________________ Date _____/_____/______

Name and Title (Print) ____________________________________________________________________________________________________________________________________

AIG Representative ______________________________________________________________________Region/Branch Code ________________________________________

AGENT INFORMATION

Company _______________________________________________________________________________________Representative ________________________________________

Address ___________________________________________________________________________________________________________________________________________________

City __________________________________________________ State ______ Zip Code ___________ Phone Number ____.____.__________

IRS Reporting Number ________________________ Dept. of Insurance License Number _________________________________________________________

To be completed by AIG Underwriting

U/W Approval

Policy Number

Effective Date

AIG Producer Code

Yes

FSI 1Q 5/07