Member Enrollment Form

Important Contact: The best way to get a hold of you.
Email

Confirmation Email
Phone Number
Type a question

Allow SMS Notification?

Employee Information: The Insured
First Name
M.I.
Last Name
Address
Address2
City
State
Zip Code

Secured Information: The Insured
Social Security
Employee Date of Birth

MonthDayYear
Gender Insured

MaleFemale

Status and Elections: The Insured
Marital Status
Status*
Status of Event Date

MonthDayYear
Insured Elected Coverage

Waive/ DeclineElect
Spouse Election Coverage

Waive/ DeclineElect
Children Under 26?

Have Child(ren) under age 26?
Elect Coverage For all Child(ren)

Waive/ DeclineElect

Employeer Information: The Insured
Employer
Occupation
Job Hire Date

MonthDayYear
Hrs Wrk Per Week
Hrs Wrk Per Week*
commission only wages?

Commission only wages

Spouse Information: General Data
Spouse First Name
Spouse M.I. name
Spouse Last name
Spouse Date Of Birth

MonthDayYear
Spouse Social Security
Spouse Gender

MaleFemale
Spouse Employment
Spouse Occupation
Spouse Employer
Height
Weight
Wife Smoker?
Smoke*
Spouse not Same address

Spouse Resides at a Different Address?
Spouse Address
Spouse City
Spouse State
Spouse Zip Code

Dependent's Medical Information: Current and Past History
WITHIN THE LAST FIVE YEARS, HAVE YOUR DEPENDENTS:
medical issues

No medical issuesHospitalizedCurrently disabled or hospital confinedHad any surgeryAdvised to have surgery, but have not done so yet
Treated Or Had Following Conditions?

Secondary or Other Insurance:

NOTE: MARRIED AND CHILDREN NEED TO BE SELECTED TO SEE OTHERS
Is there other insurance? Not Employer-provided?
Insured No Yes (Including Medicare)
Spouse No Yes (Including Medicare)
Child(ren) No Yes (Including Medicare)

Statement of Understanding (REQUIRED)

By signing this application, I represent that all my answers are complete and accurate, and that I understand and agree to the following conditions:
- No independent producer, agent or employee of the insurer, or my employer can change any part of this application or waive the requirement that I answer all questions completely and accurately.
- The insurer may, at its discretion, request supplemental information from me or any family member listed on this application or any health care provider.
- On behalf of myself and all enrolled family members, I understand if the insurer discovers any intentional misrepresentation, omission or concealment of fact in obtaining coverage that was or would have been material to the insurer’s acceptance of a risk, extension of coverage, provision of benefits or payment of any claim, the insurer may take action against me or my employer, including but not limited to increasing premiums.
- All dependents listed in the dependent sections of this form are eligible as defined by the Plan (i.e. biological, adopted or stepchild) and agree to notify my employer promptly if and when there is a change in my dependent status.
- I authorize my employer to deduct the required contribution from my earnings.
- Faxed or copied applications are not considered application and are not accepted. Application must be complete and have an original signature.
- If this application is approved, coverage for you and any eligible family members named on this application will begin on the date assigned by the insurance company.
- Coverage is only in effect after receiving written approval from the insurance company.
- Preexisting condition waiting period: Except for child(ren) under the age of 19, there are no benefits available under this policy for services, supplies, drugs or other charges that are provided within 12 months after an insured’s enrollment date for any preexisting condition. In certain circumstances, qualifying previous coverage will be credited towards the preexisting condition waiting period.
- My employer’s master group policy is the document that sets forth all terms of my coverage, and no independent producer, agent of another person can change the terms of the master group policy, or of its amendments, or this application, except with an amendment issued expressly for that purpose and signed by an authorized office of the insurer.
- I understand this application will become part of the contract between the insurer and my employer.
- I affirm that I have reviewed all answers given on this application and, regardless of whether an independent producer or other person has filled out the answers for me, I verify that the answers are true and complete.
- Any person who knowingly, and with intent to injure, defraud or deceive any insurance company, files an insurance application containing any false, incomplete or misleading information is guilty of a criminal act punishable under law.
AUTHORIZATION for the release of information

To: (1) Any licensed physician, medical practitioner, hospital, clinic, or other medically related facilities; (2) any insurance company or health maintenance organization (or similar type organization or institution); and (3) the Medical Information Bureau. I authorize you to give any data, information or records you may have about me or my mental or physical health to Assurity Life Insurance Company or Group Marketing Services, Inc. or its subsidiaries. This authorization includes information related to all conditions, treatments and diagnoses including, but not limited to: HIV/AIDS, alcohol and drug use, mental/nervous conditions. This authorization also applies to any dependent applying for coverage on this application. A photocopy of this form will be as valid as the original.
Primary Beneficiary (Full Legal Name) Signature

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Employer Approval
Company Name
Type a question

ManagementNon-Management
Type a question

HourlySalaried
Type a question

UnionNon-Union
Type a question

Commissioned Only?
Type a question

Base Salary Plus Commission?
Employment Status
Employment Status
Earnings
Employment Unit
When Paid
Enrollment Event
Enrollment Event
Date Event Happened.

MonthDayYear
Signature

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Should be Empty: