COMBINED INSURANCE COMPANY OF AMERICA
Home Office: Chicago, Illinois
Enrollment Form for Group Critical Illness Insurance
(Home Office Use)
I am applying for this coverage based on the following information:
EMPLOYEE’S (proposed insured) NAME (First MI Last)
EMPLOYEE’S HOME ADDRESS (Street, City, State, Zip)
Work Phone No.
Social Security No.
Landline Phone No.
Mobile Phone No.
Hire Date: Mo/Day/Yr
Gross Annual Income
BENEFICIARY’S Full Name
CONTINGENT BENEFICIARY’S Name
Are you actively at work at least 17½ hours each week?
Employee & Spouse
Employee & Children
Employee, Spouse & Children
List all eligible persons to be covered on this plan: Employee; Spouse; and Your Children age 26 or under.
Indicate if Employee or
Spouse used tobacco in any
form in the last 12 months
Spouse includes an Eligible Domestic Partner/Civil Union Partner who resides with and is financially interdependent with the
Employee, as defined in the Certificate.
REQUESTED BENEFIT AMOUNT:
PREMIUM - Mode
Proposed insured: __________________
See Schedule Page
See Schedule Page
Total Premium Per Pay Period:
IMPORTANT – READ CAREFULLY – I represent and affirm the following:
Express Issue (Complete as required)
1. Has any proposed insured ever been treated for or diagnosed with Acquired Immune
Deficiency Syndrome (AIDS) or “AIDS” Related Complex (ARC) or ever tested
positive for antigens or antibodies to an “AIDS” virus?
2. Within the past 10 years, have you been diagnosed or treated for any of the following:
a stroke or transient ischemic attack (TIA); heart attack, or any abnormality of the heart
or circulatory system; diabetes except gestational diabetes or any disease of the
pancreas; Emphysema, Cystic Fibrosis, or Chronic Obstructive Pulmonary Disease
(COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease;
Amyotrophic Lateral Sclerosis (ALS); Alzheimer’s Disease; Parkinson’s Disease or any
other disease or disorder of the nervous system; Multiple Sclerosis; Lupus; Sickle Cell
Anemia; or within the past 2 years taken 3 or more medications at the same time to
control high blood pressure?
3. In the last 5 years has any proposed insured been treated for or diagnosed with
cancer or any malignancy, which includes carcinoma, sarcoma, Hodgkin’s Disease,
leukemia, lymphoma, or a malignant tumor or found to have abnormal results on a
cancer screening examination or chest x-ray? Cancer does not include basal cell or
squamous cell carcinoma.
Form No. 164070