Form Il-80124-Cg - Humana Change Form Page 2
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1
2Change beneficiary
Basic Life
Primary beneficiary name
Secondary beneficiary name
Voluntary Life
Primary beneficiary name
Secondary beneficiary name
Agreement
IL-80124-AA
True and complete acknowledgement
I understand, agree and represent:
• I have read this document or it has been read to me.
• The answers provided within this entire application for coverage are to the best of my knowledge and belief, true and complete.
• Neither my employer nor the agent has the authority to waive a complete answer to any question, determine coverage or insurability,
alter any contract, or waive any of Humana’s other rights and requirements.
• If this application for coverage is accepted, coverage will be effective on the date specified by Humana on the certificate of
coverage/certificate of insurance.
• Any misrepresentation contained herein relied on by Humana may be used to reduce or deny a claim or void the contract within the
contestable period if such misrepresentation materially affect the acceptance of the risk.
I hereby enroll for benefits for which I am presently eligible or for which I may become eligible under my employer’s group contract(s). If
any deductions are required for this coverage, I authorize such deductions from my earnings. I reserve the right to revoke this deduction
authorization at any time upon written notice unless I have chosen to use pretax deductions.
This document, together with any supplements, will form part of any contract and be the basis for any certificate of coverage/certificate of
insurance issued.
Authorization
My dependents and I authorize any physician, medical practitioner, hospital, clinic, veterans administration facility, other medical or
medically-related facility, Pharmacy Benefit Manager, insurance, HMO or reinsuring company, the Medical Information Bureau, Inc., or the
Consumer Reporting Agency having information regarding myself and my dependents, including information concerning, advice, diagnosis,
treatment and care of physical, psychiatric, mental or emotional conditions, drug, substance or alcohol abuse or illness, and any other
non-medical information, to give any and all such information to Humana or their legal representative.
My dependents and I understand and agree:
• The information obtained by use of this authorization may be used by Humana to determine eligibility for coverage, eligibility for benefits
under an existing policy and plan administration.
• Any information obtained will not be released by Humana to any person or organization except to reinsuring companies, the Medical
Information Bureau, Inc. or other persons or organizations performing health care operations or business or legal services in connection
with any application, claim or as may be otherwise lawfully required, or as we may further authorize.
• We may request to receive a copy of this authorization.
• A photographic copy of this authorization shall be as valid as the original.
• This authorization shall be valid for two years from the date shown below.
Employee signature:
Date:
Spouse signature:
Date:
(If covered dependent)
IL-80124-CG
Reorder# IL-99955-CG 8/2004
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