Upon receipt of your Confirmation Form, a Certificate of Coverage will be mailed to you. For your convenience, you will be billed monthly.
By submitting initial monthly payment, 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. 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 the Hospital HELP 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 also understand I will not be covered for any Pre-Existing Conditions (injuries or sicknesses for which medical advice, care, diagnostic measures, or treatment were recommended or received within 12 months (6 months in ID, ME, NV, SD, UT and WY) immediately preceding the effective date of my coverage until 12 months from the date of my insurance coverage). I acknowledge I have received, read, and understand the disclosures.
I acknowledge that the answers provided on this application are 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proxy shall remain in effect until revoked in writing and voting in person or until the insurance plan applied for is no longer in effect.
THIS IS A LIMITED BENEFIT HEALTH COVERAGE POLICY AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.
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 crime and may be subject to imprisonment, fines, denial of insurance and civil penalties.
CA: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. NOTICE: This is a limited benefit policy. It does not provide comprehensive health insurance coverage. It does not satisfy the requirements of minimum essential coverage under the Affordable Care Act. 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.
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.
