Insurance Application Form sample
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Every day brings new projects, emails, documents, and task lists, and often it is not that different from the work you have done before. Many of our day-to-day tasks are similar to something we have done before. Don't reinvent the wheel every time you start to work on something new!
Instead, we provide this standardized Insurance Application Form template with text and formatting as a starting point to help professionalize the way you are working. Our private, business and legal document templates are regularly screened by professionals. If time or quality is of the essence, this ready-made template can help you to save time and to focus on the topics that really matter!
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Social Security : or U.S. Tax ID : Date of Birth: Date of Hire: First Name: Last Name: Mailing Address: Address Line 2: City: State: Zip: Daytime Phone: Evening Phone: E-mail Address: Name of Employer: Plan Numbers (if known): Employer City/State: Employer Zip (if known): If Plan Number is not known—Please select the Employer Plan Types for which you are enrolling (select all that apply): If the plan number is known and conflicts with a plan type selected, the plan number will dictate any type indicated herein.. By signing below, I hereby acknowledge that I understand: (1) that the effect of my consent may result in the forfeiture of benefits I would otherwise be entitled to receive upon my spouse’s death (2) that my spouse’s waiver is not valid unless I consent to it (3) that my consent is voluntary, (4) that my consent is irrevocable unless my spouse completes a new Beneficiary Designation and (5) that my consent (signature) must be witnessed by a notary public or if allowed by plan, a plan representative..
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