PLEASE NOTE: In order to be eligible to apply for this coverage, you must be an NRA member, at least 18 years old and under age 50. Your lawful spouse, under age 50 is eligible if you elect to cover them.
Upon receipt of your Coverage Request Form and your initial monthly premium, a Certificate of Insurance will be mailed to you. For your convenience, you will be billed monthly.
By submitting initial monthly payment via personal check, I understand that I’m authorizing the Plan Administrator to initiate future monthly debit entries for my regular monthly payments. I authorize future monthly debits from the same account as provided in the initial payment check. I understand my monthly payments will be processed on or after the due date and will continue to be debited from my account monthly 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 added for each automatic account billing.
I as a full-time NRA member and, if indicated, my spouse hereby enroll for Term Life Insurance coverage issued 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 monthly 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.
The answers provided on this application are representations of the person signing below. The answers given are true and complete to the best of my knowledge and belief. It is understood that CSO shall incur no liability because of this application unless and until it is approved by CSO and the first premium is paid. I understand that false or incorrect answers to the above questions may lead to rescission of coverage. If coverage is rescinded, an otherwise valid claim will be denied. I have received, read and understand the Consumer Protection Disclosures.
I understand that death benefits during the first two years of coverage will be a refund of premiums. I understand that death benefits payable on or after the third anniversary, or death benefits due to an accidental death at any time, will be the life insurance amount.
This Certificate/policy provides limited benefits. Review your certificate carefully.
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.
Fraud Warnings:
AR, DC, FL, KY, LA, MD, NJ, NM, OH, OK, PA, RI, TN, 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.
