Insurance Benefits Group Form

INSURANCE BENEFITS GROUP FORM

Group / Employer Information

Group Name:

Primary Contact: Phone:

Plan Details & Selection

Plan Type:

Coverage Level: Employee Only Employee + Spouse Family

Select Coverages (check all that apply):

Medical Dental Vision Life Insurance Accidental Death & Dismemberment Short-Term Disability Long-Term Disability

Employee / Primary Insured Information

Date of Birth: Sex:

Social Security / ID Number:

Dependent Information

Dependents to be covered (list legal name, relationship, DOB):

Beneficiary Designation

Primary Beneficiary Name:

Relationship: Percentage:

Contingent Beneficiary Name:

Relationship: Percentage:

Coverage Terms, Premiums & Effective Dates

Requested Effective Date:

Employee Premium Contribution: Employer Contribution:

Exclusions, Limitations, and Special Provisions

The policy provides coverage subject to the insuring agreements, definitions, exclusions, conditions and limitations contained in the group contract. Notwithstanding any representations made on this form, coverage is not effective until accepted by the insurer. Common exclusions include treatment related to pre-existing conditions as defined in the contract, cosmetic procedures, experimental or investigational services, and services not medically necessary as determined by the insurer.

Required Documentation Checklist

Submit with this form (check items included):
Group roster / eligible employee list
Signed enrollment forms for each member
Proof of DOB / SSN for members and dependents
Any completed waiver forms for declined coverages

Authorization, Certification and Acknowledgment

By signing below, I certify on behalf of the group and the member(s) listed that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that any material misrepresentation or omission may be grounds for rescission or denial of benefits in accordance with the group contract. I authorize the release of medical and administrative information necessary to establish eligibility and process claims. I understand that the insurer will rely on this information in determining coverage and premiums.

I further acknowledge that premiums are subject to adjustment for inaccuracies in reported enrollment or compensation, and that coverage is governed by the group policy terms, including any amendments or riders issued by the insurer.

I authorize payroll deduction or billing as indicated by employer plan procedures for the payment of employee premiums, where applicable.

I certify that I am authorized to execute this form on behalf of the named group and that I have read and understand the statements above.

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