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HomeMy WebLinkAboutEyeMed Enrollment-Change Form - Board of Director// Location Code // MI ()- -- Husband MI --// Husband MI --// Husband MI --// Husband MI --// // Last Name*Gender*: Male For additional dependents, please complete a second form. First Name*Social Security Number Date of Birth* Employee Signature*: Dependent 3 Change Type*:Add Term Update Add Term Update Relationship*:Wife Son Daughter Domestic PartnerDependent 2 Change Type*: Add First Name*Date of Birth*Social Security Number Dependent 1 Relationship*:Daughter Change Type*:Add Term Please print in all capital letters using blue or black ink. Please complete all sections. Required sections are marked with an *. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri Employee Email Address: Zip Code* Last Name* Enrollment/Change Form Date of Birth* First Name* Employee Information: to be completed by Employee Employer Information: to be completed by Employer Group Number*Subgroup* Gender* Male Female Term Update City* Phone Number Street Address* Social Security Number*^ Domestic Partner Last Name*Gender*: Male Female Dependent 4 Change Type*:Add Term Update Relationship*:Wife Son Daughter Last Name*Gender*: Male Female First Name*Social Security Number Date of Birth* Female Relationship*: Date*: ^Last four digits of Employee's Social Security Number are required. ^Date set by employer in accordance with EyeMed proposal. Employer also sets effective date for new adds during contract period. First Name*Social Security Number Date of Birth* Employer Name*Effective Date*^ State* Member ID: Wife Son Daughter Domestic Partner Male Female Last Name* Wife Son Domestic Partner Gender*: Update Family Information: to be completed by Employee. Only eligible dependents may be enrolled. Change Type*: I hereby represent that I have reviewed the fraud warning notice on the reverse side of this application for the Employee’s resident state. A-01225 FRAUD WARNING NOTICE {For residents of all states (except the following:)} {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.} {Alabama} {Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof.} {Arkansas} {Louisiana} {Rhode Island} {West Virginia} {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 is guilty of a crime and may be subject to fines and confinement in prison.} {California} {The falsity of any statement in this application will not bar the right to recovery under the Policy unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the Company.} {Colorado} {It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.} {District of Columbia} {WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.} {Florida} {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.} {Georgia} {Oregon} {Texas} {Vermont} {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 may be guilty of insurance fraud.} {Kansas} {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 may be guilty of insurance fraud as determined by a court of law.} {Kentucky} {Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.} {Maine} {It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.} {Maryland} {Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.} {Nebraska} {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 false, incomplete or misleading information is guilty of insurance fraud.} {New Jersey} {Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.} {New Mexico} {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 is guilty of a crime and may be subject to civil fines and criminal penalties.} {North Carolina} {Any person with the intent to injure, defraud, or deceive an insurer or insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties.} {Oklahoma} {WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.} {Pennsylvania} {Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.} {Tennessee} {Washington} {It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.} {Virginia} {Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.}