Insurance Family Accord Form

INSURANCE FAMILY ACCORD FORM

Policy and Insurer Details

Policy Number:    Insurer Name:

Health Life Dental Vision Disability Other:

Coverage Amount:    Deductible:    Annual Premium:

Policy Period: From to

Primary Insured / Applicant Information

Family Members To Be Covered

Cover Spouse:    Cover Domestic Partner:    Cover Children:

Dependent 1

DOB:    Relationship:    SSN Last 4 (optional):

Dependent 2 (if applicable)

DOB:    Relationship:

Dependent 3 (if applicable)

DOB:    Relationship:

Coverage Selections and Limits

Select coverages to apply to family members (check to include). For coverages with limits, state benefit limit where required.

Hospitalization (inpatient) — Limit:

Outpatient / Specialist visits — Copay/Deductible:

Maternity care — Limit:

Mental health and substance use disorder treatment

Prescription drug coverage — Formulary Tier Structure:

Exclusions and Limitations

The following are material exclusions and limitations under this Family Accord unless otherwise specifically endorsed in writing by the insurer: pre-existing conditions not disclosed at enrollment, elective cosmetic procedures, experimental or investigational treatments, injuries arising from war or hostile acts, intentionally self-inflicted injury, losses arising from illicit drug use or intoxication, and services not medically necessary as determined by the insurer. This list is illustrative and not exhaustive.

I acknowledge receipt of the exclusions above and understand that benefits will not be payable for excluded conditions or services unless a written exception is granted by the insurer:

Beneficiary Designation

Relationship:    Allocation %:

Relationship:    Allocation %:

Authorization, Certification and Terms

By signing below, I certify under penalty of law that the information provided in this Insurance Family Accord Form is true, complete, and accurate to the best of my knowledge. I authorize the insurer and its representatives to obtain and exchange medical, financial, and other records necessary to determine eligibility for coverage and to administer claims, including coordination of benefits with other payors. I further authorize any treating physician, hospital, or other provider to release such records as requested by the insurer.

I acknowledge that failure to disclose material information, including pre-existing conditions or other relevant facts, may result in denial of benefits, rescission of coverage, or premium adjustment to the effective date of the policy. I understand that coverage for family members added under this Accord is subject to the policy terms, premiums, waiting periods, and exclusions set forth by the insurer.

I agree to remit any premium payments required to maintain this family coverage and understand that coverage may be terminated for nonpayment of premiums or for material misrepresentation. This Family Accord is governed by the policy terms and applicable law.

Sign Now