Insurance UNUM Application Form

INSURANCE UNUM APPLICATION FORM

Applicant / Insured Information

Client Name:

Employment / Occupation

Full-time    Part-time    Self-employed    Unemployed

Policy Details

Requested Policy Type:
Short Term Disability    Long Term Disability    Group Life    Voluntary Life    Accidental Death & Dismemberment (AD&D)    Critical Illness

Monthly    Quarterly    Semi-Annual    Annual

Coverage Options

Select elimination period (choose one):

0 days    7 days    14 days    30 days    60 days    90 days    180 days

Benefit percentage (select one):

50%    60%    66.67%    70%

Exclusions and Limitations

The insurer will not be liable for loss or expense caused in whole or in part by: intentionally self-inflicted injury or attempted suicide; war or act of war (declared or undeclared); participation in a felony, riot, or insurrection; loss sustained while committing an illegal act; pre-existing conditions as defined in the policy; and for disabilities arising from pregnancy, childbirth or related medical conditions beyond the period expressly covered by policy provisions. Additional exclusions and limitations may apply and will be set forth in the insured policy.

Beneficiary Designation

Primary Beneficiaries (allocate 100% among primary beneficiaries)

Medical History and Underwriting Questions

Answer the following questions fully. If yes, provide details in the corresponding field below.

1. Within the past 5 years, have you been diagnosed with, treated for, or advised of any heart, circulatory, respiratory, cancer, or neurological condition?
Yes    No

2. Are you currently taking medication for any chronic condition?
Yes    No

3. Have you applied for or been declined insurance coverage for health, disability or life within the past 12 months?
Yes    No

Declarations, Authorizations and Certifications

By signing below, I certify that the information provided in this application is complete, accurate and true to the best of my knowledge. I understand that the insurer will rely on this information to determine eligibility and premium rates and that any material misrepresentation or omission may void coverage or deny a claim in accordance with the policy terms.

I authorize any physician, medical practitioner, hospital, clinic, other medical or medically-related facility, pharmacy, insurer or consumer reporting agency that has records or knowledge of me or my health to furnish to the insurer or its representatives any such information. I authorize the release of such information to the extent permitted by law for purposes of underwriting, claims administration, and fraud prevention.

I understand coverage is subject to the terms, conditions, limitations and exclusions of the policy, and that issuance is contingent upon acceptance by the insurer and payment of any required premium. I authorize any required premium deductions from my payroll or other designated payment method when applicable.

Fraud Warning: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application containing materially false information may be subject to civil and criminal penalties as permitted by law.

Authorize medical records release for underwriting and claims review    Authorize payroll deduction for premium collection (if applicable)    Affirm consent to electronic signature and records where permitted

Required Attachments Checklist

Please attach the following documents where required. Check each item you have attached:

Copy of government-issued photo ID    Most recent pay stub    Relevant medical records (if requested)    Evidence of insurability (if required)

Acknowledgment

I acknowledge that I have read and understand the statements in this application, that I have received no promise of coverage other than as may be stated in writing by the insurer, and that I will notify the employer or insurer of any material change in the information provided prior to the effective date of coverage.

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