I understand I have no obligation to pay for the Member-only NO-COST to me Patriot Protection Plan.
For Expanded Accident Protection: Upon receipt of your Enrollment form and premium payment, 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 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 on a monthly basis 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 below, my spouse hereby enroll for Accidental Death Insurance coverage 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 if I enroll in additional coverage. 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 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proxy shall remain in effect until revoked in writing and voting in person or until the insurance plan applied for is no longer in effect.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 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.
