Insurance Election Agreement

INSURANCE ELECTION AGREEMENT

Applicant / Insured Information

Date of Birth:   Residential Address:

Policy Details and Election

Effective Date:   Policy Period From: to

Coverage Election (check all that apply)

Medical Coverage — Comprehensive benefits subject to policy terms. Coverage amount:

Dental Coverage — Preventive and restorative services as described in the schedule. Annual limit:

Vision Coverage — Exams and eyewear per policy limits. Annual limit:

Group Life Insurance — Face amount:   Beneficiary designation below is binding unless superseded by a later valid designation.

Accidental Death & Dismemberment (AD&D) — Principal sum:

Short-Term Disability — Weekly benefit: Waiting period:

Long-Term Disability — Monthly benefit: Elimination period:

Critical Illness Benefit — Benefit amount:

I decline all optional coverage offered at this time. I understand this election may be subject to eligibility rules and future enrollment periods.

Beneficiary Designation (Life and AD&D)

Primary Beneficiary 1

Primary Beneficiary 2 (optional)

Exclusions and Limitations

The policy contains exclusions, limitations and waiting periods. Common exclusions include losses caused by intentional self-harm, participation in illegal acts, war or acts of war, routine cosmetic procedures, and pre-existing conditions subject to the policy's pre-existing condition provisions. Certain coverages require evidence of insurability for late enrollment or election above guaranteed issue amounts.

By checking the box below, I acknowledge that I have read the exclusions and limitations summary provided to me and that I understand the effect of those provisions on my coverage elections.

I acknowledge receipt of the exclusions and limitations summary and understand that coverage is subject to the full terms of the policy.

Payroll Deduction and Payment Authorization

Unless other payment arrangements are specified in writing and accepted by the insurer, I authorize payroll deduction of premiums required for elected coverages to the extent permitted by employer rules and applicable law. I understand premium amounts may change and that I will be notified in accordance with policy procedures.

I authorize payroll deduction of premiums for elected coverage.

Declaration and Certification

I certify that the information provided in this Insurance Election Agreement is true, complete and accurate to the best of my knowledge. I understand that any material misstatement or omission may be grounds for denial of claims or rescission of coverage as permitted by policy terms and applicable law. I authorize the insurer and the plan administrator to rely upon this signed Election Agreement and to process coverage in accordance with my selections.

I acknowledge that elections may be subject to eligibility rules, waiting periods, evidence of insurability, and that late enrollment or increases in coverage may require medical underwriting. I further acknowledge that I have received the required notices regarding portability, continuation and conversion rights where applicable under the policy.

Acknowledgment of Fraud Warning

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be subject to civil or criminal penalties in accordance with applicable law. I understand that my signature below authorizes verification of statements made on this Agreement and related documents.

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