First name:
Last name:
Authorization My dependents and I understand and agree: • The information obtained by use of this authorization may be used by Humana to make claims determinations, 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 the Group Employee Enrollment Form, claim or as may be otherwise lawfully required, or as I (we) may further authorize. Authorization for Release of Medical Records for Life If my dependents or I have selected life I authorize any third party to have information regarding myself. This includes any medical or non- medical information and to share any and all such information with Humana, its reinsurer or its legal representatives, and its affiliates. Once personal and health (including medical, dental, and pharmacy) information is disclosed pursuant to this authorization, the recipient may redisclose it and the information may not be protected by federal and state privacy requirements. The Small Group Employee Enrollment Form, together with any supplemental forms, will make up part of any contract and be the basis for any policy or certificate. Signature - please sign below if enrolling or waiving group coverage. If you decide not to sign this authorization, Humana cannot complete your plan enrollment or determine your premium rate due to the inability to obtain the necessary information. Employee / Individual or legal representative signature: ________________________________ Date: ____________________________ Name and relationship of legal representative: _____________________________________________________________________________ Spouse signature: _________________________________________________________________ Date:_____________________________ (Only if selecting Life coverage over the guarantee issue amount.)
Agent / Producer Information 1. Agent / Agency of Record:
2. Agent / Agency of Record:
Name (print)
Name (print)
Humana Agent # Commission split:
Humana Agent # Commission split:
1. Writing Agent / Producer:
2. Writing Agent / Producer:
Name (print)
Name (print)
Humana Agent # Commission split:
Humana Agent #
Commission split: Will the coverage selected replace or change any existing life insurance policy(s) and/or annuity(s)? m N m Y As the Writing Agent / Producer, I acknowledge that I am responsible to meet with the primary applicant submitting the Small Group Employee Enrollment Form in order to fully and accurately represent the terms and conditions of the plans and services of the offering or insuring entity, or one of its subsidiaries. These provisions are available to me and the primary applicant in the benefit summary document or other plan literature. Signed at _______________________________________________________________________________ _________________________ County State
Writing Agent’s Signature _________________________________________________________________
Date __ __/__ __/__ __ __ __
The original version of this Agreement is in the English language. If there are any discrepancies or conflicts between the English and any other version that has been translated into another language, the English version will control.
GA-72000 10/2015
5
Reorder# GA-52000-SB 1/2018
21 Slappey & Sadd, LLC 2025 Benefits Guide |
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