I hereby represent that the statements and answers to the questions on this application are to the best of my knowledge and belief, full, complete and true. I understand that they will form the basis of any coverage under the Group Plan for which Evidence of Insurability is required.
Also, it is mutually understood and agreed that (1) the Company reserves the right to request, at its expense that I be examined by an accredited medical examiner selected by the Company; (2) no Group Insurance will be binding or in force until satisfactory evidence of insurability is submitted and approved by the Insurance Company at the Home Office as shown in the Endorsement; and (a) I am actively at work on a full-time basis (as defined in the Group Plan) for full pay on the date my Group Insurance becomes effective; otherwise, (b) I will become insured on the date I do return to work and satisfy these requirements ; (3) no person, except the President, a Vice President or a Secretary of the Company, has authority to: (a) determine whether any contract(s) of insurance shall be issued on the basis of the application; (b) waive or modify any of the provisions of the application or any of the Company’s requirements; (c) bind the Company by any statement or promise pertaining to any insurance contract(s) issued or to be issued on the basis of the application; or (d) accept any information or representation not contained in the written application; (4) the administrator is hereby named the Proposed Insured’s representative for the purpose of receiving premiums and remitting them to the Company.
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.Investigative Consumer ReportI authorize
The Guardian Life Insurance Company of America or its legal representative to obtain or have prepared an investigative report as described in the Insurance Information Practices Notice.Medical Records and Other InformationI authorize
any physician, medical practitioner, hospital, clinic, other health facility, the Medical Information Bureau, insurance or reinsurance company, or employer to release any and all medical and non-medical information in its possession about me to The Guardian Life Insurance Company of America or its legal representatives. Medical information means all information in the possession of or derived from providers of health care regarding the medical history, mental or physical condition, or treatment of me. I understand The Guardian Life Insurance Company of America will use the information obtained by this authorization to determine eligibility for insurance or eligibility for benefits under an existing plan. Guardian will not release any information obtained to any person or organization except to reinsurance companies, the Medical Information Bureau, or other persons or organizations performing business or legal services in connection with my application, claim or as may be lawfully permitted or required, or as I may further authorize.I know
that I may request and receive a copy of this authorization.I agree
that a photocopy of this authorization will be as valid as the original.I acknowledge
receipt of and have read Guardian’s Insurance Information Practices Notice
regarding its Insurance Information Practices, the Fair Credit Reporting act, the Medical Information Bureau and Medical Records.I agree
that this authorization will be valid for two and one half years from the date shown below.
If Monthly Auto Pay selected
I hereby authorize Business Planning Concepts, Inc dba Member Benefits, herein referred to as "Member Benefits" to initiate debit entries and to initiate, if necessary, credit entries as adjustments for any debit entries in error to my Checking account and the Financial Institution named below to debit and/or credit the same account. Member Benefits will not be held responsible for a policy lapse or cancellation due to nonpayment if withdrawal is prepared and not honored for any reason and amount due is not paid. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law and that Member Benefits and the Financial Institution may discontinue this service.
This authority is to remain in full force and effective until Member Benefits and the Financial Institution have received written notice from me of its termination in such time and manner as to afford Member Benefits and the Financial Institution a reasonable opportunity to act on it. Note: If the ACH debit is returned for non-sufficient funds, a $25 nonrefundable service fee will be applied when allowed by law.
ABN Membership Agreement
I hereby apply for membership in the American Association of Business Networking (ABN). Upon completion of this enrollment form and payment of initial dues ($2.00 monthly), I understand that: (a) I will be entitled to ABN’s benefits; (b) these benefits may change from time to time; (c) my membership will become effective on the day this enrollment form is dated and signed; (d) I am eligible to apply for association group insurance; and (e) I authorize the release of my name and address listed on the Application for Insurance to ABN.