Combined Insurance Company Of America Enrollment Form (Page 2 of 2) in pdf

Proposed

Insured

Spouse

Simplified Issue (Complete additional questions as required)

Yes

1. a. Have two or more members of any proposed insured’s immediate family (natural

parents, brothers or sisters, either living or deceased) had the same condition

(cancer other than skin cancer, diabetes, heart disease or stroke) diagnosed

prior to age 60?

b. Has any proposed insured been hospitalized or treated in the emergency room

for a sickness in the past six months?

2. Within the past 2 years has any proposed insured been diagnosed or treated for

alcohol or drug abuse or been arrested for a DUI?

Name of proposed insured

Height

Weight

Employee

Spouse

If proposed insured has answered “Yes” to any of the above questions:

Question No.

Name of proposed

Details (include the condition/illness, dates,

insured/Spouse/Childr(en)

and doctor’s name & address)

It is very important that you review your enrollment form carefully. Misstatements or omissions could cause an otherwise valid claim

to be denied.

CONFIDENTIALITY OF MEDICAL INFORMATION

The medical information disclosed on this Enrollment Form will not be disclosed to the employer or any other person without the

authorization of the proposed insured.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I authorize Combined Insurance Company of America or its reinsurers to acquire from and authorize any hospital, physician, medical

practitioner, clinic, pharmacy, pharmacy benefits manager or other pharmacy-related services organization, medically related facility,

insurance company, or consumer reporting agency to release to Combined Insurance Company of America any information regarding

me or my past or present health for the purpose of evaluating this Enrollment Form for insurance. I also authorize Combined Insurance

Company of America or its reinsurers to disclose all such information to any physician, or any other insurance company in order to

evaluate a claim or an application for insurance.

This authorization shall remain valid for a period of two years from the issue date of the coverage. A photocopy of this authorization

will be as valid as the original. A copy of the authorization is available to me or my representative upon request to Combined.

I understand that any insurance will not take effect unless and until Combined Insurance Company of America approves

my enrollment. If coverage cannot be issued as requested under the rules of the Company, I authorize Combined Insurance

Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer

to deduct the premiums for this insurance from my earnings (unless the coverage for which I am requesting allows for alternate

methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is

true and complete to the best of my knowledge and belief.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or

statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any

fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

X _____________________________________

City: _____________________

State: _________

Date: ______________

Signature of Employee

I, the authorized agent, have on the date of application recorded the information as given to me by the Employee.

Signature of Licensed Agent ______________________________________________

Code # __________________________

REMARKS OR SPECIAL REQUESTS FOR CONVERSION OR CERTIFICATE CHANGE

Form No. 164070

Combined Insurance Company Of America Enrollment Form Page 2

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