I hereby represent that to the best of my knowledge and belief, no person to be insured under this policy has received treatment for* or been medically advised of Cancer (excluding Skin Cancer) within the last 5 years (3 years in LA & MT; 2 years in IL, TN & VT; 12 months in CT, IN, MD, MO, MS, NC, ND, SC, TX & VA; 6 months in ID, ME, NH, NV, SD, UT & WY).
It is understood that no benefits will be payable for expenses incurred during the first 12 months of coverage for any cancer diagnosed or treated within the first 30 days after the insured person’s effective date of coverage.
Upon approval, a Certificate of Insurance will be mailed to you. For your convenience, you will be billed monthly.
I and, if indicated above, my spouse hereby enroll for the Cancer Care Insurance Plan as provided by Central States Health & Life Co. of Omaha (CSO). I understand that my 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 I have received, read, and understand the disclosures.
*(Treatment means medical and surgical care by a licensed provider to detect or cure Cancer. This includes examination, diagnostic procedures, surgery (including pre- and post-operative care), prescribed medication, and the application of remedies and therapy. It does not include any diagnostic procedures or examinations performed to monitor a previous removal or remedy of Cancer, provided there is no positive diagnosis of Cancer or of a recurrence of Cancer.)
The undersigned hereby agrees to appoint the President and/or Secretary of CSO 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proxy shall remain in effect until revoked in writing and voting in person or until the insurance plan applied for is no longer in effect.
Fraud Warnings:
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.
CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.
