MY SIGNATURE ON THIS APPLICATION CERTIFIES THAT I: 1) Apply for the coverages designated for which I am eligible under my employer’s plan with Union Security Insurance Company. 2) Understand if coverages have been refused, I am not entitled to benefits under those coverages and that if I want to apply later, I must furnish at my own expense proof of good health satisfactory to Union Security Insurance Company. For Dental coverage, I understand that I will not be entitled to benefits until the expiration of any Late Entrant Limitation period specified in the policy. 3) Authorize any required deductions from my earnings. 4) Designate the beneficiary named on this application to receive any benefits payable in the event of my death. 5) Represent that all of the information on this application is complete, correct and true to the best of my knowledge and belief. 6) Understand that I must be actively at work the number of hours specified in the policy/participation agreement to remain insured. 7) Understand that I have the right to select any dental care provider of my choice. 8) Understand that the dental plan includes a pre-estimate provision that will advise me in advance of the benefits I may be eligible for if the procedure is performed. 9) Understand that coverages include waiting periods, limitations, and exclusions and a pre-existing conditions provision that may affect my entitlement to benefits. When necessary, I may be asked to execute a HIPAA authorization form, allowing Union Security Insurance Company to use and disclose protected health information. 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.
Employee’s signature_ ______________________________________________________ Date ____________________
AGENT, BROKER, AND/OR ENROLLER INFORMATION: Agency Name: _ _________________________________________ Agent/Broker Name: _ _________________________________________ Enroller Name: _ _________________________________________
Application 197790_219521_1_082304_00001_00001 Page 3 of 4
Form 61 (03/2010)
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