Combined Insurance Company Of America Enrollment Form printable pdf download

COMBINED INSURANCE COMPANY OF AMERICA

Home Office: Chicago, Illinois

Enrollment Form for Group Critical Illness Insurance

FORM #C16670

(Home Office Use)

Enrollment Date:

I am applying for this coverage based on the following information:

ACTION REQUESTED:

New Certificate

Reinstatement

Conversion

Certificate Change

EMPLOYEE’S (proposed insured) NAME (First MI Last)

Birthdate: Mo/Day/Yr

Age

Male

Female

EMPLOYEE’S HOME ADDRESS (Street, City, State, Zip)

Work Phone No.

Social Security No.

Employee ID#

Landline Phone No.

Mobile Phone No.

EMPLOYER NAME

POLICYHOLDER NAME

Hire Date: Mo/Day/Yr

Gross Annual Income

BENEFICIARY’S Full Name

Relationship

CONTINGENT BENEFICIARY’S Name

Relationship

Are you actively at work at least 17½ hours each week?

Yes

COVERAGE FOR:

Employee Only

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

Name(s)

DOB: Mo/Day/Yr

Relationship

Sex

form in the last 12 months

(as above)

Self

(as above)

Yes

Spouse

Yes

Child 1

Child 2

Child 3

Child 4

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: __________________

Weekly (52)

Monthly (12)

Bi-Weekly (26)

See Schedule Page

Spouse:

Semi-Monthly (24)

___________

See Schedule Page

Child(ren):

Total Premium Per Pay Period:

IMPORTANT – READ CAREFULLY – I represent and affirm the following:

Proposed

Insured

Spouse

Express Issue (Complete as required)

Yes

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

Combined Insurance Company Of America Enrollment Form

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