Ltc Short Form Application For Current - University Of Texas System (Page 3 of 3) in pdf

SECTION 6 – AUTHORIZATION

NOTICE: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud

against an insurer, submits an application or files a claim containing a false or deceptive statement,

may have violated the laws in his or her state.

I understand and agree that the statements in this application are complete and true to the best of my

knowledge and belief and that they will form a part of the contract of insurance. I also understand and agree

that the insurance for which I am applying, if issued, shall be based on these statements.

Authorization to Obtain Information

“Information Provider” as used herein may include any physician, medical practitioner, hospital, clinic, other

medical or medically related facility, clearinghouse, insurance or reinsuring company, agent, broker, service

provider, Medical Information Bureau, Inc. (MIB), credit bureau or other consumer reporting agency, employer

or the Veterans Administration.

“Information” received from an Information Provider may include advice, diagnosis, prognosis, treatment or

care of any physical or mental condition concerning me, including information about HIV or AIDS, drug or

alcohol abuse or mental illness (except psychotherapy notes) and/or financial, consumer report, or any other

non-medical information concerning me.

I AUTHORIZE any Information Provider to give Continental Casualty Company (the Company) any and all

Information regardless of any previous restriction or limitation on disclosure of such Information. In order to

expedite my request, I further authorize an Information Provider (except MIB) to release Information to the

Company’s agents, brokers, service providers, its reinsurers, or any other third party retained by the Company

to collect and transmit such Information.

I UNDERSTAND that the Information obtained by use of this Authorization is at my request and will be

collected by the Company to determine eligibility for insurance. I understand that this Authorization to Obtain

Information shall remain valid for two years from the date shown below. I understand that if I do not sign this

Authorization, the Company may not accept my application for insurance.

I UNDERSTAND that the Company may maintain or have access to personal information acquired separately

through any of my previous insurance applications with the Company or its affiliates for insurance even in

instances where insurance was not placed with me.

I authorize the Company to use or disclose such

information for consideration of my current application for insurance.

I UNDERSTAND that I may revoke this Authorization at any time by providing written notice to the Company,

except: (i) to the extent that an individual has taken action in reliance upon such authorization prior to notice of

the revocation, or (ii) to the extent that this authorization was provided as a condition of obtaining insurance

coverage and other law provides the Company with the right to contest a claim for coverage under the policy or

the insurance coverage under the policy itself.

I UNDERSTAND that Information disclosed pursuant to this Authorization may be subject to re-disclosure by

the recipient and no longer the responsibility of the Information Provider or protected by the privacy rule under

the Health Insurance Portability and Accountability Act.

I UNDERSTAND I may request to receive a copy of this Authorization and I agree that a photographic copy of

this Authorization shall be as valid as the original.

I CERTIFY that I have read, or had read to me, the completed application. All statements in this application

are representations and not warranties. If this application is accepted, the insurance will take effect on the

effective date shown on the schedule page attached to the certificate of coverage.

Caution Notice: If your answers on this application are incorrect or untrue, the Continental Casualty

Company may have the right to deny benefits or rescind your coverage, subject to the incontestability

provisions in the policy.

Applicant’s Signature

Date

Coverage is not guaranteed and is based on the information provided.

ZG-119896-A-42

AG-140590-D

6/2013 Printed in the USA

Ltc Short Form Application For Current - University Of Texas System Page 3

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