I understand and agree with the following statements:
• My dependents are not eligible for coverages I don't have. My dependents, including step and foster children and
any over the maximum age, are eligible based on plan provisions but those over the maximum age will be verified
when a claim is filed.
• If I refuse dental or vision coverage, I and my dependents may enroll later but this will affect the level of benefits.
• If I refuse coverage, I cannot enroll after retirement.
• If the group policy does not require my contribution, I cannot decline coverage unless the policy indicates otherwise.
• If the group policy requires my contribution, I authorize my employer to deduct from my pay.
• I represent all information on this form and attachments is complete and true to the best of my knowledge. They are part of this request for coverage. I agree Principal Life is not liable for a claim before the effective date of coverage
and all policy provisions apply. I have read, or had read to me, the information and my answers on this form. During the first two years coverage is in force, fraud or intentional misrepresentations can cause changes in my coverage,
including cancellation back to the effective date.
• Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, is guilty of insurance fraud.
• Explanation of Benefits reflecting claims payments for myself and my dependents will be sent to my home address. I also understand collection of social security numbers for myself and/or my dependents will be used by Principal Life
only as allowed by law.
• I authorize Principal Life to release data as required by law. If signed in connection with an application, reinstatement or a change in benefits, this form will be valid two years from the date below. I may revoke authorization for information not yet obtained. I understand data obtained will be used by Principal Life for claims administration and determining eligibility for life, disability, and critical illness. Information will not be used for any purposes prohibited by law.
• I understand that as the employee, the insurance I and my dependents have applied for will begin on the effective date of coverage provided I am at work on that date. If I am not actively at work on such date, subject to the terms
of the group policy, coverage may not go into effect until after my return to work. Furthermore, I understand that no insurance may become effective for any member of my family while he/she is in a period of limited activity.
A copy of this form will be as valid as the original.
I declare that the information I have completed on this enrollment form is complete and true. I understand an agent or broker cannot guarantee coverage, revise rates, benefits or provisions without written approval from Principal Life Insurance Company.