B Employer
Employee name (last, first, initial)
C
Buchanan Hauling & Rigging, Inc.
Group policy/participant # B Account #
B Cert. #
B Employee SSN
B Employee birthdate
Multiple
IMPORTANT NOTICE TO APPLICANTS - PLEASE READ CAREFULLY AUTHORIZATION TO RELEASE INFORMATION: To properly underwrite applications, determine eligibility for coverage and issue insurance policies on an equitable basis, we must obtain information about you. The nature of the information we seek includes age, occupation, physical condition, health history, habits, avocations and other personal characteristics and information. This information will be collected from you and various sources, including health professionals and health facilities. Information regarding factors affecting insurability will be treated as confidential. By signing below, I authorize any provider of medical services, physicians, or other medical practitioner, hospital, clinic, pharmacy, pharmacy benefits manager or any pharmacy related services entity, insurance company, employer, consumer reporting agency, or other individual or entity to give Union Security Insurance Company or its reinsurers any information regarding my medical or health history. Such information includes but is not limited to any and all medical/dental records relating to my physical and/or mental health, alcohol or drug abuse information, psychiatric or psychological care or pharmacy records. I understand that I have the right to refuse to sign this authorization but if I refuse, Union Security Insurance Company may refuse to consider my application for enrollment. I understand that a photocopy or facsimile of this authorization will be as valid as the original. I understand that this authorization is voluntary and that I may revoke it at any time by writing Union Security Insurance Company, P.O. Box 419052, Kansas City, MO 64141-6052, Attn: Privacy Office. Such revocation will not affect any action taken by Union Security Insurance Company prior to receipt of the revocation. If there is a conflict between a prior request for restrictions and this authorization, this authorization controls. The authorization is effective from the date signed below until the earliest of denial of my application, declination of enrollment, or, if insured, when I am no longer an insured of Union Security Insurance Company, but at no time longer than 30 months. Federal law requires that we inform you that the information which we collect may, under certain circumstances, be re- disclosed by us to third parties and thus no longer protected by federal law. However, be assured that disclosure will be strictly limited to that which is reasonably necessary and we will comply with all federal and state privacy and security laws and regulations. You have the right to gain access to and request correction of information contained in our files. 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. 3) Represent that all of the information on this application is complete, correct and true to the best of my knowledge and belief. 4) Understand that I must be actively at work the number of hours specified in the policy/participation agreement to remain insured. 5) Understand that coverages include waiting periods, limitations, and exclusions and a pre-existing conditions provision that may affect my entitlement to benefits. This will certify that I HAVE read and understand the above important notice. 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____________________
Spouse’s signature (if spouse coverage elected)_________________________________Date____________________
Health 197790_219521_1_082304_00001_00001 Page 2 of 4
Form 73 (04/2009)(IN)
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