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DECLARATION AND AGREEMENT — I/We have personally completed and reviewed all of my/our answers to the questions in this Application and represent that all information I/we have provided is true, complete, and correctly recorded. I/We understand that this information will be used to determine each person’s eligibility for coverage under the Policy and any false statement or misrepresentation may result in loss of coverage or claim denial. The Applicant (and Spouse or Dependent if coverage elected) must be eligible based on the Company’s rules in effect on the date of Application and on the Policy Effective Date. Policy coverage (or Reinstatement of coverage), if issued and approved by the Company, will become effective on the date recorded in the Policy Schedule of Benefits and not the date this Application is signed. I/We understand that no agent or producer can accept risks, modify policies, or waive any rights or requirements of the Company. If this Application is completed electronically, I/we agree that my/our electronic signature serves as my/our original signatures.
ACKNOWLEDGEMENT — I/We understand that the coverage applied for provides limited benefits and is not a major medical or comprehensive medical benefit plan and is not a substitute for such coverage. The Policy is limited and is not designed to cover all medical expenses. I/We understand that no benefits are payable for sickness during the first 30 days following the Policy Effective Date and that pre-existing conditions are excluded for 12 months. If eligible for Medicare, I/we have received the Guide to Health Insurance for People with Medicare and the Important Notice to Persons on Medicare.
WARNING — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
THIS IS A LIMITED BENEFIT POLICY. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. PLEASE REVIEW THE POLICY CAREFULLY
I/We hereby authorize any: physician, medical practitioner, hospital, clinic or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, pharmacy benefit manager, government agency, group policyholder, employer, benefit plan administrator, MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to STANDARD LIFE AND ACCIDENT INSURANCE COMPANY, or to any agent, attorney, consumer reporting agency or independent administrator, including medical record retrieval services or pharmaceutical services, acting on STANDARD LIFE AND ACCIDENT INSURANCE COMPANY’S or its reinsurers’ behalf, information concerning advice, care or treatment sought by or provided to me and/or any other Proposed Insured for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, and/or drug, alcohol or tobacco usage of the Applicant or any Proposed Insured. It is understood that STANDARD LIFE AND ACCIDENT INSURANCE COMPANY underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I/We understand that after this information is disclosed, the recipient may redisclose it, resulting in loss of protection by federal regulations.
I/We understand that:
This authorization is valid from the date signed for a duration of 24 months. I/We understand I/we may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Health Underwriting Department of STANDARD LIFE AND ACCIDENT INSURANCE COMPANY, P.O. Box 1991, Galveston, Texas 77553. I/We may inspect or copy any information used or disclosed under this authorization, if signed. If this application is taken over the phone, I/we agree that my/our electronic signature serves as my/our original signature.
If the Applicant or Proposed Insured holds one of these occupations, please check the box next to that individual’s name in the application. These individuals will not be eligible for coverage with the Standard Life product.
Ultimate protection for what’s most important
For maximum protection, the Ultimate Plan is the first and only cybersecurity solution to provide all the features you need to stay safe.
With every aspect of our lives represented online, your personal information and identity are constantly at risk. Between working remotely, online shopping and banking, medical records, and social media, our need for protection is greater than ever.
Data breaches, hacking, and identity theft are on the rise — and it’s a problem that affects everyone, regardless of gender, age, race, income, and location.1 Today, cybercriminals are more skilled at spotting even the smallest vulnerabilities than ever before.
While á la carte identity theft protection can protect you in some areas, there is only one product that can provide complete peace of mind with the maximum protection for every area of your life.
Aura Identity Guard Digital Halo is the only solution on the market that provides comprehensive protection for every area of your digital life.
Powered by IBM® Watson™ AI, Identity Secure provides 24/7 identity theft monitoring and alerts you to Dark Web activity, new accounts, and other suspicious activity. Identity Secure stops fraud and identity theft in its tracks within minutes, as well as keeps your children safe online through intuitive cyberbullying capabilities and social media monitoring.
|Near Real-Time Alerts|
|Credit and debit card monitoring|
|Bank account transaction monitoring|
|401(k) investment account monitoring|
|Student loan activity alerts|
|High Risk Transaction Monitoring|
|Bank Account Opening & Takeover Monitoring|
|Criminal Record Monitoring|
|Fictious Identity Monitoring|
|Home Title Monitoring|
|Sex Offender Monitoring|
|Dark Web Monitoring|
|Stolen fund reimbursement|
|401(k) and HSA reimbursement|
|$1,000,000 Identity Theft Insurance|
|Security Freeze Assistance|
|Risk Management Score|
|Social Insight Report|
|Lost Wallet Protection|
|1-Bureau Credit Monitoring|
|3-Bureau Credit Monitoring|
|3-Bureau Annual Credit Report|
|Monthly Credit Score|
|Credit Score Tracker|
Protecting your physical devices – including computers, tablets, and mobile phones – has never been easier. Device Secure shields your personal data through VPN, safe browsing, and robust anti-virus tools. With Device Secure, you’ll enjoy around-theclock, fortress-like protection while you browse safely, avoiding malware, ransomware, spyware, and viruses.
|Safe Browsing Software|
Privacy Secure puts you in control of your personal data. Your information is proactively removed from data broker/aggregator lists and people-finder sites, which reduces unsolicited, preapproved credit offers and other spam, and unauthorized use of your personal data.
|Device/cookie tracking protection|
|E-mail solicitation/junk mail prevention|
|Data broker list monitoring/removal|
Your coverage effective date is based on the payment method elected (ACH or Payroll Deduction).
ACH: Coverage effective date is the 1st of the month following date of enrollment.
Payroll Deduction: If the enrollment is received on or before the 23rd of the month, the effective date will be the first of the month following 60 days. IF after the 23rd of the month, the coverage will begin on the first of the month following 90 days.
Yes. You must elect ACH payment. Payroll deduction will not be available.
Yes. You must elect ACH payment.
On your next payroll deduction if the enrollment is received on or prior to the 23rd of the month.
Your initial payment will be taken within 3 business days of completing your enrollment. After initial payment, your scheduled draft date will be the 1st of each month.
“8888593795 Insurance” will appear on your statement as a description of the charge for your premiums.
No. A person may be covered only once under the plan as an Employee, Spouse or Dependent Child.
No. A member must elect coverage for him/herself in order to be eligible to elect family coverage.
On/Around your coverage beginning, you will recieve an email from Identity Guard with instructions and a link to their webstie where you and your covered family members can register.
Identity Guard customer service is available Monday - Friday, 8am -11pm (EST) and Saturday 9am - 6pm (EST) at 855-443-7748 or via email at firstname.lastname@example.org.