Upon receipt of your Benefits Confirmation form, a Certificate of Coverage will be mailed to you. For your convenience, you will be billed monthly.
By submitting initial payment, I understand that I’m authorizing the Plan Administrator to initiate future monthly debit entries for my regular payments. I authorize future debits from the same account as provided in the initial payment. I understand my payments will be processed on or after the due date and will continue to be debited from my account until the Plan Administrator has received and has had reasonable time to act on my request to cancel by telephone at 1-877-672-3006. A $1.25 monthly administrative fee will be included in the total monthly amount charged for each automatic monthly account billing. By signing below, I understand these terms and authorize recurring payments.
I and, if indicated, my spouse hereby enroll for Accidental Death Insurance coverage as provided by Central States Health & Life Co. of Omaha (CSO). I understand that my Accidental Death Insurance coverage will become effective on the Effective Date stated in the Schedule, provided my first payment is paid and received by the Plan Administrator. I understand any cash benefit checks will be payable as outlined above subject to policy provisions. I acknowledge that the information provided on this application is true and complete to the best of my knowledge and belief.
The undersigned hereby agrees to appoint CSO’s President and/or Secretary the continuing proxy to vote for the applicant at any annual, regular or special meetings of the Company at which the applicant is not present. The annual meeting of members shall be held each year in the home office (1212 North 96th Street, Omaha, Nebraska 68114) on the second Tuesday of January at 10:00 a.m. This proxy shall remain in effect until revoked in writing and voting in person or until the insurance plan applied for is no longer in effect.
The certificate/policy provides limited benefits. Review your certificate/policy carefully.
Fraud Warnings:
AR, CA, DC, KY, LA, MD, NJ, OH, OK, PA, VA, WV:
WARNING: Any person who knowingly, willfully, or with intent presents materially false, incomplete, misleading or fraudulent information for the purpose or intent of deceiving or defrauding an insurer is guilty of a crime and may be subject to imprisonment, fines, denial of insurance and civil penalties.
CA: Fraud warning: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement
in state prison.
