Insurance Group Life Policy

Insurance Group Life Policy

Group Sponsor / Policy Identification

Class / Division:    Total Active Members:

Effective Date (Policy Inception):    Policy Period From: to

Insured Information

Date of Birth:    Social Security Number / Tax ID:

Occupation / Title:    Date Employed by Group:

Coverage Options and Schedule of Benefits

Coverage Type (select applicable): Basic Group Life Voluntary/Supplemental Life Accidental Death & Dismemberment (AD&D) Dependent Life Waiver of Premium for Disability

Benefit Calculation / Formula:

Premium and Billing

Premium Amount:    Frequency:

Employer Paid Portion (if any):    Employee Payroll Deduction Authorization:

Exclusions, Limitations and Termination

The insurer will not be liable for loss caused by or resulting from the following. These exclusions are enforceable notwithstanding any other provision of this policy:

1. Suicide or intentionally self-inflicted injury within the first twenty-four (24) months of coverage unless otherwise provided under state law.
2. Loss sustained while committing or attempting to commit an illegal act or while engaged in an illegal occupation.
3. War, declared or undeclared, or any act of war, except as otherwise required by mandatory law.
4. Loss resulting from active participation in a felony, riot, or insurrection.
5. Injury or disease arising out of aviation other than as a fare-paying passenger on a scheduled airline.

Termination of Coverage: Coverage for an insured will terminate upon the earliest of the following events: cessation of employment with the group; termination of the policy; failure to pay required premiums subject to the grace period; attainment of the termination age stated above; or fraudulent misstatement of material facts in this application or related enrollment forms.

Beneficiary Designation

Beneficiary designations supersede prior beneficiary designations on file with the employer unless otherwise indicated. Percentages must total 100%.

Relationship:    Percentage:

Relationship:    Percentage:

Relationship:    Percentage:

Claims Notice and Requirements

Notice of claim must be provided to the insurer as soon as reasonably possible. The insurer may require proof of loss, including but not limited to the following documents:

Certified Death Certificate

Employer Statement of Employment and Salary

Attending Physician's Statement / Medical Records

Police Report (if applicable)

Other Documents as Requested

Conversion and Portability

Upon termination of group coverage, an insured may be eligible to convert coverage to an individual life policy or elect portability subject to the terms, conditions, and eligibility requirements of the insurer. Requests for conversion must be submitted in writing within the time period specified by the policy and accompanied by any required premium.

General Provisions, Representations and Certifications

The insured represents that all statements made in this application are true and complete to the best of the insured's knowledge. Material misstatements or omissions may render coverage voidable or result in denial of claim if such misstatements or omissions are material to the risk accepted by the insurer. The insurer shall have the right to require proof of insurability for any coverage subject to underwriting approval.

Incontestability: Except for fraud or intentional misrepresentation of material fact, the validity of this coverage shall not be contested after it has been in force for a period of time as provided in the policy. Where applicable, state-mandated incontestability provisions shall control.

Authorization: By signing below, the insured authorizes the release of any medical information reasonably required to process claims and administer this policy, and authorizes payroll deduction for employee-paid premiums where applicable. This authorization remains in effect for policy administration, claims adjudication, and the duration of any period during which benefits are payable.

Acknowledgment and Signature

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I acknowledge receipt of the policy terms, coverage descriptions, exclusions, and requirements for filing a claim. I understand that coverage is subject to the terms and conditions of the master policy issued to the group.

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