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Disability Insurance Online Application & Electronic Signature Agreement

Consumer Disclosure Regarding Conducting business electronically, Receiving Electronic Notices and Disclosures, and Signing Documents Electronically

Please read the following information, by proceeding forward and signing this document you are agreeing that you have reviewed the following consumer disclosure information and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. This electronic signature service is provided on behalf of Business Planning Concepts, Inc dba Member Benefits "sending party" herein referred to as "Member Benefits", the administrator of the AIT Disability Insurance Plan, whom are sending electronic documents, notices, disclosures or requesting electronic signatures to you.

You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time as described below.


Paper Copies

You are not required to receive notices or disclosures or sign documents electronically and may request paper copies of documents or disclosures if you prefer to do so. You also have the ability to download and print any open or signed documents sent to you through the electronic signature system. Member Benefits may also email you a PDF copy of all agreements you sign using the service. If you wish to receive paper copies in lieu of electronic documents you may close this web browser and request paper copies from Member Benefits by following the procedures outlined below.

Use of the Service requires a standards-compliant web-browser which supports the HTTPS protocol, HTML, and cookies. Viewing PDF documents requires additional software such as Adobe Reader or similar.


Withdrawal of Consent

You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify Member Benefits that you wish to withdraw consent and to provide your future documents, notices, and disclosures in paper format. After withdrawing consent if at any point in the future you proceed forward and utilize the electronic signature system you are once again consenting to receive notices, disclosure, or documents electronically. You may withdraw consent to receive electronic notices and disclosures and optionally electronically signatures by following the procedures described below.


Scope of Consent

You agree to receive electronic notices, disclosures, and electronic signature documents with all related and identified documents and disclosures provided over the course of your relationship with Member Benefits. You may at any point withdraw your consent by following the procedures described below. You agree to receive communications from Member Benefits regarding coverage, program availability, and other important updates via email. Your privacy is extremely important to us; we do not sell personally identifiable information to outside parties, and we follow strict security standards. You have the ability to change email delivery preferences and/or opt out at any time. For a full summary of our privacy practices, please visit the Privacy Policy page.


Requesting paper copies, withdrawing consent, and updating contact information

You will have the ability to download and print any documents you complete through the electronic signature system. To request paper copies of documents, withdraw consent to conduct business electronically and receive documents, notices, or disclosures electronically or sign documents electronically, please contact Member Benefits by telephone (800) 282-8626, or by sending an email to (support@memberbenefits.com) with the following subjects:

 

“Requesting Paper Copies” Please provide your name, email, telephone number, postal address and document title.

 

“Withdraw Consent” Please provide your name, email, date, telephone number, postal address.

 

“Update Contact Information” Please provide your name, email, telephone number and postal address.

(Please enter your valid email address to conduct business electronically. Your eSignature ready application will be emailed to this address.)

Disability Insurance Information

The sum of all Group Disability Benefits cannot exceed 60% of an applicant’s insured earnings as defined by Guardian.
Elimination Period*
Period of time you must be disabled before benefits are payable.
Elimination Period*
Period of time you must be disabled before benefits are payable.
Maximum Payment Period*
Maximum length of time benefits are payable.
Maximum Payment Period*
Maximum length of time benefits are payable.
Optional Benefits
Add Optional Cost of Living (COLA) Benefit & Critical Disability Supplement

Applicant's Information

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Name*
Address*

Applicant's Information (cont.)

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Date of Birth*
$

Medical History Questions

Please check reason for completing*
Feet/Inches
Lbs.
1. Ever applied to Guardian for Insurance?*
2. Ever been rated, declined, for life, accident or health insurance or ever had such insurance postponed, modified or renewal declined, or received disability for more than 6 months?*
3. Ever been treated by a medical professional for or diagnosed as having the HIV infection?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)

Medical History Questions (cont.)

In the past 10 years, have you been treated for or diagnosed as having:

If you answer is "Yes" to any of the questions below, please provide SPECIFIC additional information about your answer. The more information you provide during your application, the faster your application can be processed.

4a. High blood pressure, chest pain or disorder of the heart or circulatory system?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4b. Diabetes, cancer, tumor, or disorder of the glands, bone or skin?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4c. Complications of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs, prostate, kidneys, or urinary system?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4d. Hernia, hepatitis, or disorder of the liver, gall bladder, stomach, intestines or rectum?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4e. Arthritis, rheumatism, or disorder of the joints, limbs or muscles?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)

Medical History Questions (cont.)

In the past 10 years, have you been treated for or diagnosed as having:

4f. Disorder or condition of the back, neck or spine?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4g. Allergy, asthma, sinusitis, emphysema, or disorder of the lungs or respiratory system?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4h. Epilepsy, stroke, dizziness, headache, or disorder of the brain or spinal cord?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4i. Disorder of the eyes, ears, nose, or throat?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4j. Anxiety, depression, nervousness, stress, mental or nervous disorders, or other emotional disorder?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4k. Chronic Fatigue Syndrome, Epstein Bar virus or Lyme Disease?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
4l. Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC); or any other disorder of the immune system?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)

Medical History Questions (cont.)

5. Within 10 years ever used drugs other than as prescribed by a physician; been advised to have treatment or been treated for drug abuse or alcoholism?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
6. In the past year had: fever persisting more than one month; significant involuntary weight loss; diarrhea persisting more than one month; oral candidiasis (thrush); lymphadenopathy (enlarged or swollen glands)?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)

Medical History Questions (cont.)

In the past 5 years, have you:

7a. consulted or been examined by or treated by a physician, practitioner, or specialist? Do not include routine annual physicals unless: (1) they were in connection with an existing or prior medical condition; (2) existing symptoms were being checked; or (3) a specific medical condition was found.*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
7b. been in a hospital, sanitarium, or other institution for observation, diagnosis, treatment, or an operation?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
7c. been prescribed medication(s)?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)

Medical History Questions (cont.)

8. In the last 12 months used tobacco in any form?*
9. Any loss of hearing or sight, an amputation of any kind, any physical deformity, impairment or handicap?*
Please list condition, dates, duration of symptoms, treatment & degree of recovery, attending physician(s) name, address, and facility (i.e hospital name)
10. Are you pregnant?*
10. If Yes, any complications with your pregnancy?*
11. In the last 2 years, have you participated in any of the following avocations:*
11. In the last 2 years, have you participated in any of the following avocations:
  Yes No
(a) piloting any type of aircraft?
(b) mountain climbing?
(c) scuba diving below 100 feet?
(d) skydiving?
(e) motor vehicle racing?
(f) martial arts?
12. In the past two years, had a driver’s license suspended or revoked, or had 3 or more moving violations, or been charged with driving under the influence of alcohol or drugs?*

Payment Information

Secure transactions for this website utilize an SSL Certificate to ensure secure transmission of your information.


Payment Option 1 - Monthly Auto Pay
If you elect to pay by Monthly Bank Draft (ACH), you do not need to send any premium. Upon approval of your application, we will automatically draft your account on a monthly basis.



Payment Option 2 - Direct Annual Billing
By selecting this method, if you are approved for coverage, you will receive your certificate of insurance and an initial invoice for the required premium to pay your coverage up through the end of the plan year (Dec. 31st). Thereafter, you will be billed on a calendar annual basis.

IMPORTANT: Do not use numbers from a deposit ticket as these numbers are often different than your checking ABA and Account number's. Routing and Account number must be from an authorized Checking account. An actual check is the best source to acquire the proper routing information.

IMPORTANT:

Monthly Auto Pay ACH Transactions from your bank account are performed by the plan administrator Member Benefits. Please make sure to recognize us on your bank statement as:


MEMBERBENEFITS92

Application Agreement

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 Report
I 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 Information
I 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.
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 Report
I 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 Information
I 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.
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E-Sign Application

You have one-step left to complete your application.

 

After clicking the "ESign Application" button below, check your email for your signature ready application. You will receive an email from our RightSignature esignature tool. Please click the link provided in the email and E-sign your application. Please note, certain data fields on your e-signature ready application have been hidden for identity protection purposes.

 

If you do not receive your e-signature ready application via email, please contact us at 1-800-282-8626.

 

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