Allstate Enrollment Form

ENROLLMENT AND EVIDENCE OF INSURABILITY FORM

AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL)

1776 American Heritage Life Drive, Jacksonville, Florida 32224

GENERAL INFORMATION

Employee’s/Payor’s/Owner’s (Certificateholder) Name (Last, First, M.I.) M F Social Security Number

Residence Address City State Zip

Date of Birth Phone Number Email

Employer/Association/Union Date Hired Occupation Plant Or Division

Primary Beneficiary’s Full Name and Address City State Zip Relationship

Phone Number Date of Birth Social Security Number

Contingent Beneficiary’s Full Name and Address City State Zip Relationship

Phone Number Date of Birth Social Security Number

COMPLETE THIS SECTION FOR PERSONS TO BE INSURED

SELECTION OF COVERAGE

Are you changing any existing coverage due to a qualifying event such as marriage, birth, or adoption? Yes No

Qualifying Event Date of Qualifying Event Current Certificate Number(s)

Do you currently have any of the following individual coverages with American Heritage Life Insurance Company (AHL)?

Accident Yes No Cancer Yes No

Policy Number Termination Effective Date

Premium/Billing Mode Bi-weekly

Date of First Deduction Coverage Effective Date Account Number Employee ID Situs State

EVIDENCE OF INSURABILITY

Please complete each question applicable to coverages selected.

Question 1: Is any person to be insured actively at work now, for wage or profit, and has he/she worked at least 20 hours each week performing all duties of his/her regular occupation at his/her regular place of employment for at least 3 months except for minor illness or injury of 1 week or less, or normal pregnancy?

Employee Yes No Spouse Yes No Child(ren) Yes No

Question 2: Has any person to be insured, in the last 10 years, tested positive for exposure to HIV or been diagnosed with AIDS or ARC caused by HIV or other related condition?

Employee Yes No Spouse Yes No Child(ren) Yes No

Question 3: Has any person to be insured, in the last year, been diagnosed with a systolic blood pressure reading higher than 150 more than once or a diastolic blood pressure reading higher than 100 more than once?

Employee Yes No Spouse Yes No Child(ren) Yes No

Question 4a: Has any person to be insured ever been diagnosed with or treated for any type of cancer, other than basal cell carcinoma?

Employee Yes No Spouse Yes No Child(ren) Yes No

Question 4b: If yes to 4a, has that person been diagnosed with Leukemia, Hodgkin’s Disease, Lymphoma, or cancer with any lymph node involvement or more than one metastasis?

Employee Yes No Spouse Yes No Child(ren) Yes No

Question 4c: If yes to 4a, has that person been diagnosed with or treated for any other type of cancer in the last 5 years?

Employee Yes No Spouse Yes No Child(ren) Yes No

Question 5: Has any person to be insured, in the last 5 years, been diagnosed with or treated for a stroke, transient ischemic attack (TIA), heart attack, heart condition, heart trouble, any abnormality of the heart, or any artery disease?

Question 6: Has any person to be insured ever been diagnosed with or treated for any of the listed conditions?

Height Weight

Question 8: Provide health history for any “Yes” answers. Include physician’s name, address, and telephone number.

ELECTRONIC ACCEPTANCE

By checking the “Yes” box, I elect electronic delivery of my certificate(s) of insurance and/or policy(ies), including accompanying documents.

Yes No

By checking the “Yes” box, I elect electronic delivery of all contractual, regulatory, and administrative correspondence.

Yes No

Email address for electronic delivery

Agent (Producer) information

Agent (Producer) Name Servicing Agent (Producer) Soliciting Agent (Producer)

Florida Agent License Number Agent (Producer) Number National Agent (Producer) Number (NPN) Percentage Credit

IMPORTANT NOTICE TO PERSONS ON MEDICARE

THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance.

This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when it pays:

• Hospital or medical expenses up to the maximum stated in the policy

Medicare generally pays for most or all of these expenses.

Before You Buy This Insurance

• Check the coverage in all health insurance policies you already have.

• For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

• For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIIP).

SIGNATURE SECTION