Deep South 2017 Deep_South_2017 Web Self-Service
8037444825 edi@selerix.com Web Self-Service 0 Unknown Chubb Accident CIC_ACC_CI Chubb Critical Illness CIC_GCI_CI Chubb Accident CIC_ACC_CI Chubb Critical Illness CIC_GCI_CI DI Selected Bundles Smoker CIC_114159_Actively_at_Work #bodyContent_MainCtrl_PersonDIP_STD_EMPLOYED_THIRTY_b6e5be1a-dc00-44e3-b8ad-1ff269d1eec9 { width: 825px; height: 80px; } #contentContent { clear:both; } #bodyContent_MainCtrl { } #bodyContent_MainCtrl_MainCtrl_table { } .questionCtrl-global{ margin-top: 2px; padding:2px; background:#f5f5f5; border:1px solid #ddd; overflow:auto; } .questionCtrl-row { padding:5px; overflow:hidden; } *{ box-sizing: border-box; } .questionCtrl-global > .questionCtrl-parent, .questionCtrl-global > ..questionCtrl-sub { float: left; width: 65%; } .questionCtrl-global > .questionCtrl-answer, .questionCtrl-global > .questionCtrl-answer-under { float: right; width: 33%; text-align: left; } div { display: block; } .lead { margin-top: 0px; }
Are you actively at work at least <%=Event.Engine.Properties["min_hours_per_week"]; %> hours each week?
]]> CIC_114159_Authorization_Language
<% switch (Event.EnrollmentState) { case 'DE': %>

It is very important that you review your enrollment form very carefully. Misstatements or omissions could cause an otherwise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined Insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings ( unless the coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on the Application is true and complete to the best of my knowledge and belief. No person listed on this enrollment form is covered by Medicaid.
<% break; case 'MN': %>

It is very important that you review your enrollment form very carefully. Misstatements or omissions could cause an otherwise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
<% break; case 'MT': %>

It is very important that you review your enrollment form very carefully. Misstatements or omissions could cause an otherwise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.

<% break; default: %>

It is very important that you review your enrollment form carefully. Misstatements or omissions could cause an other wise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined Insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.

<% break; } %>]]> CIC_114159_Fraud_Language

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 and denial of insurance benefits.
<% break; case 'AL': %>

Any person who knowingly presents a false or fraudulent claim for payment of a 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.
<% break; case 'AR': %>

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.
<% break; case 'CA': %>

The falsity of any statement in the application for any policy shall 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 risk or the hazard assumed by Combined.
<% break; case 'CO': %>

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.
<% break; case 'DC': %>

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.
<% break; case 'FL': %>

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.
<% break; case 'KS': %>

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 may be guilty of insurance fraud as determined by a court of law.
<% break; case 'KY': %>

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.
<% break; case 'LA': %>

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.
<% break; case 'MD': %>

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.
<% break; case 'NJ': %>

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
<% break; case 'NM': %>

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..
<% break; case 'OH': %>

Any person who, with 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 be guilty of insurance fraud.
<% break; case 'OK': %>

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, imcomplete or misleading information is guilty of a felony.
<% break; case 'OR': %>

Any person who, with 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 be guilty of insurance fraud.
<% break; case 'RI': %>

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.
<% break; case 'TN': %>

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 and denial of insurance benefits.
<% break; case 'VA': %>

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 and denial of insurance benefits..
<% break; default: %>

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 aperson to criminal and civil penalties.
<% break; } %>]]> CIC_164070_Actively_At_Work CIC_164070_Tobacco Indicate if <%=hiText;%> used tobacco in any form in the last 12 months.]]> CIC_164070_Set_Parameters CIC_164070_AIDS 1. Has any proposed insured ever been treated for or diagnosed with Acquired Immune Deficiency Syndrome (AIDS) or "AIDS" Related Complex (ARC)? <%}else if(state == 'CT'){%> 1. To the best of your knowledge and belief, has any proposed insured ever been treated for or diagnosed with Aquired Immune Deficincy Syndrome (AIDS) or "AIDS" related complex (ARC)? <%}else if(state == 'FL'){%> 1. Has any proposed insured been tested positive for exposure to the HIV infection or been diagnosed by a licensed medical professional as having Acquired Immune Deficency Syndrome (AIDS) or AIDS Related Complex (ARC) caused by the HIV infection or other sickness or condition derived from such infection. <%}else if(state == 'GA'){%> 1. Within the past 10 years has any proposed insred been treated for or diagnosed with Acquired Immune Defiency Syndrome (AIDS) or "AIDS" Related Complex (ARC) or ever tested positive for antigens or antibodies to an "AIDS" virus? <%}else if(state == 'ID'){%> 1. In the past 10 years has any proposed insred been treated for or diagnosed with Acquired Immune Defiency Syndrome (AIDS) or "AIDS" Related Complex (ARC) or ever tested positive for antigens or antibodies to an "AIDS" virus? <%}else if(state == 'IL'){%> 1. Has any proposed insured ever been treated for or diagnosed with Acquired Immune Deficiency Syndrome (AIDS) or “AIDS” Related Complex (ARC) or ever tested positive for antigens or antibodies to an “AIDS” virus by a licensed member of the medical profession? <%}else if(state == 'MD'){%> 1. Within the past 7 years, has any proposed insured been treated for or diagnosed with Acquired Immune Deficiency Syndrome (AIDS) or “AIDS” Related Complex (ARC) or tested positive for antigens or antibodies to an “AIDS” virus? <%}else if(state == 'ME'){%> 1. Has any proposed insured been treated for or diagnosed with Acquired Immune Defiency Syndrome (AIDS) or "AIDS" Related Complex (ARC) or ever tested positive for antigens or antibodies to an "AIDS" virus? NOTE: Answer this question "No" if you have tested positive for HIV but have not developed symptoms of the disease AIDS. <%}else if(state == 'NJ'){%> 1. Has any proposed insured ever been treated for or diagnosed with Acquired Immune Defiency Syndrome (AIDS) or "AIDS" Related Complex (ARC) or ever tested positive for antigens or antibodies to an "AIDS" virus by a licensed member of the medical profession? <%}else if(state == 'VT'){%> 1. Has any proposed insured ever been treated for or been diagnosed by a licensed medical physician as having Acquired Immune Deficiency Syndrome (AIDS) or “AIDS” Related Complex (ARC)? <%}else{%> 1. Has any proposed insured ever been treated for or diagnosed with Acquired Immune Deficiency Syndrome (AIDS) or "AIDS" Related Complex (ARC) or ever tested positive for antigens or antibodies to an "AIDS" virus? <%}%> ]]> CIC_164070_Diseases 2. Within the past 10 years, have you been diagnosed or treated for any of the following: a stroke or transient ischemic attach (TIA); heart attack, or any disease or disorder of the heart or circulatory system, diabetes except gestational diabetes or any disease of the pancreas; Emphysema, Cystic Fibrosis or Chrinic Obstructive Pulmonary Disease (COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease; Amyotrophic Lateral Sclerosis (ALS); Alzheimer's Disease; Parkinson's Disease or any other disease or disorder of the nervouse system; Multiple Sclerosis; Lupus; Sickle Cell Anemia; or within the past 2 years taken 3 or more medications at the same time to control high blood pressure?<% break; case 'ID': %>2.In the past 10 years, have you been diagnosed or treated for any of the following: a stroke or transient ischemic attack (TIA); heart attack, or any abnormality of the heart or circulatory system; diabetes except gestational diabetes or any disease of the pancreas; Emphysema, Cystic Fibrosis or Chronic Obstructive Pulmonary Disease (COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease; Amyotrophic Lateral Sclerosis (ALS); Alzheimer's Disease; Parkinson's Disease or any other disease or disorder of the nervous system; Multiple Sclerosis; Lupus; Sickle Cell Anemia; or within the past 2 years taken 3 or more medications at the same time to control high blood pressure?<% break; case 'IN': %>2. Within the past 5 years, have you been diagnosed or treated for any of the following: a stroke or transient ischemic attack (TIA); heart attack, or any abnormality of the heart or circulatory system; diabetes except gestational diabetes or any disease of the pancreas; Emphysema, Cystic Fibrosis, or Chronic Obstructive Pulmonary Disease (COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease; Amyotrophic Lateral Sclerosis (ALS); Alzheimer’s Disease; Parkinson’s Disease or any other disease or disorder of the nervous system; Multiple Sclerosis; Lupus; Sickle Cell Anemia; or within the past 2 years taken 3 or more medications at the same time to control high blood pressure?<% break; case 'FL': %>2. Within the past 10 years, have you been diagnosed or treated by a licensed medical professional for any of the following: a stroke or transient ischemic attack (TIA); heart attack, or any abnormality of the heart or circulatory system; diabetes except gestational diabetes or any disease of the pancreas; Emphysema, Cystic Fibrosis, or Chronic Obstructive Pulmonary Disease (COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease; Amyotrophic Lateral Sclerosis (ALS); Alzheimer’s Disease; Parkinson’s Disease or any other disease or disorder of the nervous system; Multiple Sclerosis; Lupus; Sickle Cell Anemia; or within the past 2 years taken 3 or more medications at the same time to control high blood pressure?<% break; case 'MD': %>2. Within the past 7 years, have you been diagnosed or treated for any of the following: a stroke or transient ischemic attack (TIA); heart attack, or any abnormality of the heart or circulatory system; diabetes except gestational diabetes or any disease of the pancreas; Emphysema, Cystic Fibrosis, or Chronic Obstructive Pulmonary Disease (COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease;<% break; case 'ME': %>2. Within the past 10 years, have you been diagnosed or treated for any of the following: a stroke or transient ischemic attack (TIA); heart attack, or any abnormality of the heart or circulatory system; diabetes except gestational diabetes or any disease of the pancreas; Emphysema, Cystic Fibrosis, or Chronic Obstructive Pulmonary Disease (COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease; Amyotrophic Lateral Sclerosis (ALS); Alzheimer’s Disease; Parkinson’s Disease or any other disease or disorder of the nervous system; Multiple Sclerosis; Lupus; Sickle Cell Anemia; or within the past 2 years taken 3 or more medications at the same time to control high blood pressure?<% break; case 'MN': %>2. Within the past 10 years, have you been diagnosed or treated by a member of the medical profession for any of the following: a stroke or transient ischemic attack (TIA); heart attack, or any abnormality of the heart or circulatory system; diabetes except gestational diabetes or any disease of the pancreas; Emphysema, Cystic Fibrosis, or Chronic Obstructive Pulmonary Disease (COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease; Amyotrophic Lateral Sclerosis (ALS); Alzheimer’s Disease; Parkinson’s Disease or any other disease or disorder of the nervous system; Multiple Sclerosis; Lupus; Sickle Cell Anemia; or within the past 2 years taken 3 or more medications at the same time to control high blood pressure?<% break; default: %>2. Within the past 10 years, have you been diagnosed or treated for any of the following: a stroke or transient ischemic attack (TIA); heart attack, or any abnormality of the heart or circulatory system; diabetes except gestational diabetes or any disease of the pancreas; Emphysema, Cystic Fibrosis or Chrinic Obstructive Pulmonary Disease (COPD); any disease or disorder of the liver; kidney failure or end stage kidney disease; Amyotrophic Lateral Sclerosis (ALS); Alzheimer's Disease; Parkinson's Disease or any other disease or disorder of the nervous system; Multiple Sclerosis; Lupus; Sickle Cell Anemia; or within the past 2 years taken 3 or more medications at the same time to control high blood pressure?<% }%>]]> CIC_164070_Cancer 3. In the last 5 years has any proposed insured been treated for or diagnosed with cancer or any malignancy, which includes carcinoma, sarcoma, Hodgkin's Disease, leukemia, lymphoma, or a malignant tumor? Cancer does not include basal cell or squamous cell carcinoma.<% break; case 'ID': %>3. In the past 10 years has any proposed insured been treated for or diagnosed with cancer or any malignancy by a licensed medical professional, which includes carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or a malignant tumor or found to have abnormal results on a cancer screening examination or chest x-ray? Cancer does not include basal cell or squamous cell carcinoma.<% break; case 'FL': %>3. In the last 5 years has any proposed insured been treated for or diagnosed with cancer or any malignancy by a licensed medical professional, which includes carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or a malignant tumor or found to have abnormal results on a cancer screening examination or chest x-ray? Cancer does not include basal cell or squamous cell carcinoma.<% break; case 'MD': %>3. In the last 5 years has any proposed insured been treated for or diagnosed with cancer or any malignancy, which includes carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or a malignant tumor or found to have abnormal results on a cancer screening examination or chest x-ray? Cancer does not include basal cell or squamous cell carcinoma<% break; case 'MN': %>3. In the last 5 years has any proposed insured been treated for or diagnosed by a member of the medical profession with cancer or any malignancy, which includes carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or a malignant tumor or found to have abnormal results on a cancer screening examination or chest x-ray? Cancer does not include basal cell or squamous cell carcinoma.<% break; default: %>3. In the last 5 years has any proposed insured been treated for or diagnosed with cancer or any malignancy, which includes carcinoma, sarcoma, Hodgkin's Disease, leukemia, lymphoma, or a malignant tumor or found to have abnormal results on a cancer screening examination or chest x-ray? Cancer does not include basal cell or squamous cell carcinoma.<% }%> ]]> CIC_164070_Confidentiality

It is very important that you review your enrollment form carefully. Misstatements or omissions could cause an otherwise valid claim to be denied.

The medical information disclosed on this Enrollment Form will not be disclosed to the employer or any other person without the authorization of the proposed insured.

 ]]> CIC_164070_Authorization
I authorize Combined Insurance Company of America or its reinsurers to acquire from and authorize any hospital, physician, medical parctitioner, clinic, pharmacy, pharmacy benefits manager or other pharmacy-related services organization, medically related facility, insurance company, Government Agency; Medical Information Bureau, Inc. (MIB); or consumer reporting agency to release to Combined Insurance Company of America any medical records or other health history information (excluding HIV/AIDS/ARC) concerning me and any dependent listed on my enrollment form for the purpose of evaluating this Enrollment Form for insurance. I also authorize Combined Insurance Company of America or its reinsurers to disclose all such information to any physician, the Medical Information Bureau, Inc., or any other insurance company in order to evaluate a claim or an application for insurance.
I understand that Federal and state laws protect the information disclosed pursuant to this authorization. However, any disclosure of information carries with it the potential for any unauthorized re-disclosure and the information may not be protected by the federal confidentiality rules. The nature of this authorization release request is to allow Combined's Underwriters to seek and obtain medical information from this entities listed in the previous paragraph to be used in determining my insurability.
This authorization shall remain valid for a period of 30 months from the issue date of the coverage. A photocopy of this authorization will be as valid as the original. A copy of the authorization is available to me or my representative upon requet to Combined. I understand that I may revoke this authorization at anytime by writing Combined; however, such revocation may affect coverage. Faulure to sign this authorization may impair the ability of Combined to evaluate or process this application and may be a basis for denying this application. I understand that any insurance will not take effect unless and until Combined Insurance Copany of America approves my enrollment. If coverage cannot be issued as requested under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am requesting allows for alternate methods to pay insurance premiums).
In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
<% break; case 'ID': %>
I authorize Combined Insurance Company of America or its reinsurers to acquire from and authorize any hospital, physician, medical parctitioner, clinic, pharmacy, pharmacy benefits manager or other pharmacy-related services organization, medically related facility, insurance company or consumer reporting agency to release to Combined Insurance Company of America any information regarding me or my past or present health for the purpose of evaluating this Enrollment Form for insurance. I also authorize Combined Insurance Company of America or its reinsurers to disclose all such information to any physician, or any other insurance company in order to evaluate a claim or an application for insurance.
This authorization shall remain valid for a period of two years from the issue date of the coverage. A photocopy of this authorization will be as valid as the original. A copy of the authorization is available to me or my representative upon requet to Combined.
I understand that any insurance will not take effect unless and until Combined Insurance Copany of America approves my enrollment. If coverage cannot be issued as requested under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am requesting allows for alternate methods to pay insurance premiums).
In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief. No proposed insured to be covered is also covered under Title XIX program such as Medicaid. Additionally, I acknowledge that I have recieved an outline of coverage.
<% break; case 'ME': %>
I authorize Combined Insurance Company of America or its reinsurers to acquire from and authorize any hospital, physician, medical parctitioner, clinic, pharmacy, pharmacy benefits manager or other pharmacy-related services organization, medically related facility, insurance company or consumer reporting agency to release to Combined Insurance Company of America any information regarding me or my past or present health for the purpose of evaluating this Enrollment Form for insurance. I also authorize Combined Insurance Company of America or its reinsurers to disclose all such information to any physician, or any other insurance company in order to evaluate a claim or an application for insurance.
This authorization excludes disclosure of the result of a test for HIV if the applicant has test positive for HIV buthas not developed symptoms of the diease AIDS. Such test shall not be discovered or published. Nothin in this caveat will prohibit this authorization from including the fact that the applicant has AIDS.
This authorization shall remain valid for a period of two years from the issue date of the coverage. A photocopy of this authorization will be as valid as the original. I understand that I, or my authorized representitative, may request a copy of this authorization from Combined Insurance Company of America. I may also revoke this authorization by writing to the company; however, such revocation may affect my coverage. Failure to sign thid authorization may affect the ability of Combined Insurance Company of America to process my enrollment and may result in the denial of my enrollment form.
I understand the any insurance will not take effect unless and until Combined Insurance Company of America approves my enrollment. If coverage cannot be issued as requested under the rules of the Company, I authorize Combinded Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am requesting allows for alternate methods to pay insurance premiums.)
In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief. I acknowledge receipt of the outline coverage.
I affirm that I am NOT covered by any Title XIX program (Medicaid).
THis certificate does not meet the federal requirement to have health care coverage under the Affordable Care Act.
<% break; case 'MN': %>
I authorize Combined Insurance Company of America or its reinsurers to acquire from and authorize any hospital, physician, medical parctitioner, clinic, pharmacy, pharmacy benefits manager or other pharmacy-related services organization, medically related facility, insurance company or consumer reporting agency to release to Combined Insurance Company of America any information regarding me or my past or present health for the purpose of evaluating this Enrollment Form for insurance. I also authorize Combined Insurance Company of America or its reinsurers to disclose all such information to any physician, or any other insurance company in order to evaluate a claim or an application for insurance.
This authorization shall remain valid for a period of two years from the issue date of the coverage. A photocopy of this authorization will be as valid as the original. A copy of the authorization is available to me or my representative upon requet to Combined.
I understand that any insurance will not take effect unless and until Combined Insurance Copany of America approves my enrollment. If coverage cannot be issued as requested under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am requesting allows for alternate methods to pay insurance premiums).
In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
The coverage enrolled for does not cover Pre-existing Conditions unless the date of diagnosis for such condition is at least 12 months after the Certificate Effective Date. Pre-Exsisting Condition means a condistion for which a Covered Person recieved medical advice or treatment within 12 months preceding the Certificate Effective Date.
<% break; case 'UT': %>
I authorize Combined Insurance Company of America or its reinsurers to acquire from and authorize any hospital, physician, medical parctitioner, clinic, pharmacy, pharmacy benefits manager or other pharmacy-related services organization, medically related facility, insurance company or consumer reporting agency to release to Combined Insurance Company of America any information regarding me or my past or present health for the purpose of evaluating this Enrollment Form for insurance. I also authorize Combined Insurance Company of America or its reinsurers to disclose all such information to any physician, or any other insurance company in order to evaluate a claim or an application for insurance.
This authorization shall remain valid for a period of two years from the issue date of the coverage. A photocopy of this authorization will be as valid as the original. A copy of the authorization is available to me or my representative upon requet to Combined. I understand that any insurance will not take effect unless and until Combined Insurance Copany of America approves my enrollment. If coverage cannot be issued as requested under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am requesting allows for alternate methods to pay insurance premiums). No person covered for critical illness shall also be covered by any Title XIX program, designated as Medicaid or any similar name.
In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
<% break; case 'VT': %>
I authorize Combined Insurance Company of America or its reinsurers to acquire from and authorize any hospital, physician, medical practitioner, clinic, pharmacy, pharmacy benefits manager or other pharmacy-related services organization, medically related facility, insurance company or consumer reporting agency to release to Combined Insurance Company of America any information regarding me or my past or present health for the purpose of evaluating this Enrollment Form for insurance. I also authorize Combined Insurance Company of America or its reinsurers to disclose all such information to any physician, or any other insurance company in order to evaluate a claim or an application for insurance.
Note: This authorization excludes the release of any information about previously administered tests for HIV antibodies, T-cell counts, AIDS or ARC. The proposed insured/applicant is not authorizing the company to forward results from any new test required by the company to any outside, non-affiliated company of any other entity not under specific contract to perform underwriting services. I understand this consent may be revoked in writing at any time with the exception to the extent that disclosure of information has already occurred prior to the receipt of revocation by the above named provider. If written revocation is not received, authorization will be considered valid for a period of time not to exceed 90 days from the date of signing. This authorization shall remain valid for a period of two years from the issue date of the coverage. A photocopy of this authorization will be as valid as the original. A copy of the authorization is available to me or my representative upon request to Combined.
I understand that any insurance will not take effect unless and until Combined Insurance Company of America approves my enrollment. If coverage cannot be issued as requested under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am requesting allows for alternate methods to pay insurance premiums).
In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
<% break; default: %>
I authorize Combined Insurance Company of America or its reinsurers to acquire from and authorize any hospital, physician, medical parctitioner, clinic, pharmacy, pharmacy benefits manager or other pharmacy-related services organization, medically related facility, insurance company or consumer reporting agency to release to Combined Insurance Company of America any information regarding me or my past or present health for the purpose of evaluating this Enrollment Form for insurance. I also authorize Combined Insurance Company of America or its reinsurers to disclose all such information to any physician, or any other insurance company in order to evaluate a claim or an application for insurance.
This authorization shall remain valid for a period of two years from the issue date of the coverage. A photocopy of this authorization will be as valid as the original. A copy of the authorization is available to me or my representative upon requet to Combined.
I understand that any insurance will not take effect unless and until Combined Insurance Copany of America approves my enrollment. If coverage cannot be issued as requested under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am requesting allows for alternate methods to pay insurance premiums).
In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
<%if(Event.EnrollmentState == 'RI'){%> This is a LIMITED BENEFIT CRITICAL ILLNESS CERTIFICATE.
It does not cover all of the essential health benefits required by the Affordable Care Act. Depending upon your household income and other personal circumstances, you may be subject to federal penalties after January 1, 2014 unless you are covered under a health insurance plan with essential health benefits.
Do you need help finding affordable health insurance coverage that best fits your health care needs? HealthSource RI, Rhode Island’s health benefits exchange, is a new way for Rhode Islanders to find, compare, and purchase health insurance. You or your family may qualify to receive tax credits to help pay for insurance, to enroll in low-cost or no cost insurance options. To answer your questions, and to help you find a health insurance plan, you can contact the HealthSource RI support team on-line, by phone, in person, or by mail.
On-line: visit www.healthsourceri.com
By phone: call toll free at 885-574-2843. 7 days a week, Monday - Saturday 8 am - 9 pm, Sunday noon - 6 pm.
In person: To find the HealthSource RI office near you, call 885-574-2843 or walk in at 70 Royal Little Drive, Providence, RI 02904.
By mail: HealthSource RI, Hazard Building Mailroom, 75 West Road, Ste 500, Cranston, RI 02920.
I acknowledge that I have received the Notice to Rhode Island Residents regarding HealthSource RI and understand this is a limited benefit certificate. <%} }%>
]]> CIC_164070_Fraud
The falsity of any statement in the application for any policy shall 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 risk or the hazard assumed by Combined.
<% break; case 'CO': %>
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.
<% break; case 'DC': %>
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.
<% break; case 'FL': %>
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.
<% break; case 'GA': %>
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 may be guilty of insurance fraud.
<% break; case 'KS': %>
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 may be guilty of insurance fraud as determined by a court of law.
<% break; case 'KY': %>
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.
<% break; case 'LA': %>
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.
<% break; case 'OR': %>
Any person who, with 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 be guilty of insurance fraud.
<% break; case 'TN': case 'VA': %>
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 and denial of insurance benefits.
<% break; default: %>
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.
<% }%>

By clicking the “Next” button you are providing Combined Insurance with your consent to execute these application forms via electronic means. At any time you wish to make a change to any benefit, you must go through the entire electronic enrollment process again and again click the “I Accept” button because changing any data invalidates this authorization.
]]> 2017-09-25T07:26:13
USA 6851 GREENWOOD ROAD SHREVEPORT LA 71119
sso@selerix.com 464-21-3776 HSPL Selerix Male Deep South Equipment, Inc. 2017-09-20T00:00:00 2017-09-20T00:00:00 <Department>Deep South</Department> <Location>Deep South</Location> <JobClass>Deep South</JobClass> <PayGroup>Bi-Weekly</PayGroup> <PayrollFrequency>26</PayrollFrequency> <DeductionFrequency>26</DeductionFrequency> <Salary>1000.0000</Salary> <HourlyWage>0.0000</HourlyWage> <FTERate>0.0000</FTERate> <HoursPerWeek>40</HoursPerWeek> <PTOBalance>0.0000</PTOBalance> <PTOCost>0.0000</PTOCost> <FederalTax>0</FederalTax> <FederalUnemploymentTax>0</FederalUnemploymentTax> <StateUnemploymentTax>0</StateUnemploymentTax> <SocialSecurityTax>0</SocialSecurityTax> <MedicareTax>0</MedicareTax> <WorkersComp>0</WorkersComp> <Bonus>0</Bonus> <Commissions>0</Commissions> <Overtime>0</Overtime> <StockOptionGrantValue>0</StockOptionGrantValue> </Employment> <LegalStatus>Employee</LegalStatus> <Relationship>Employee</Relationship> <BirthDate>1987-08-09T00:00:00</BirthDate> <SmokerStatus>Never</SmokerStatus> <Student>false</Student> <Disabled>false</Disabled> <EmployeeIdent>326</EmployeeIdent> <PIN>377687</PIN> <EnrollmentSession Status="Complete"> <Location>Deep South</Location> <City>Shreveport</City> <State>LA</State> <EnrollerID>Web Self Service</EnrollerID> <EnrollerAssisted>false</EnrollerAssisted> <EnrollmentType>Unknown</EnrollmentType> <LastStatusUpdate>2017-09-22T06:48:27</LastStatusUpdate> <Offerings /> <Journal /> </EnrollmentSession> <PaymentInfo> <PaymentType>Payroll</PaymentType> <BankDraftDay>0</BankDraftDay> </PaymentInfo> <Questionnaire> <Answer QuestionID="DI Selected Bundles"> <Name>DI Selected Bundles</Name> <Value>0</Value> </Answer> <Answer QuestionID="Smoker"> <Name>Smoker</Name> <Value /> </Answer> <Answer QuestionID="CIC_114159_Actively_at_Work"> <Name>CIC_114159_Actively_at_Work</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Authorization_Language"> <Name>CIC_114159_Authorization_Language</Name> </Answer> <Answer QuestionID="CIC_114159_Fraud_Language"> <Name>CIC_114159_Fraud_Language</Name> </Answer> <Answer QuestionID="DI Selected Bundles"> <Name>DI Selected Bundles</Name> <Value>0</Value> </Answer> <Answer QuestionID="Smoker"> <Name>Smoker</Name> <Value /> </Answer> <Answer QuestionID="CIC_164070_Actively_At_Work"> <Name>CIC_164070_Actively_At_Work</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_164070_Tobacco"> <Name>CIC_164070_Tobacco</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_164070_Set_Parameters"> <Name>CIC_164070_Set_Parameters</Name> <Value>Cgi</Value> </Answer> <Answer QuestionID="CIC_164070_AIDS"> <Name>CIC_164070_AIDS</Name> <Value>False</Value> </Answer> <Answer QuestionID="CIC_164070_Diseases"> <Name>CIC_164070_Diseases</Name> <Value>False</Value> </Answer> <Answer QuestionID="CIC_164070_Cancer"> <Name>CIC_164070_Cancer</Name> <Value>False</Value> </Answer> <Answer QuestionID="CIC_164070_Confidentiality"> <Name>CIC_164070_Confidentiality</Name> </Answer> <Answer QuestionID="CIC_164070_Authorization"> <Name>CIC_164070_Authorization</Name> </Answer> <Answer QuestionID="CIC_164070_Fraud"> <Name>CIC_164070_Fraud</Name> </Answer> </Questionnaire> </Applicant> </Applicants> <Applications> <Application ID="f87c128c-9aac-41fd-b9be-74e87868e1e0" UniqueID="f87c128c-9aac-41fd-b9be-74e87868e1e0" EmployeeID="e47234e3-b058-4c4d-887a-3cc217b23c07" ApplicantID="e47234e3-b058-4c4d-887a-3cc217b23c07" IncreaseEffectiveImmediate="false" ShowErrorMessages="false" Status="Complete"> <AsOfDate>2017-09-22T18:19:08</AsOfDate> <OfferingID>17583</OfferingID> <Coverage ProductID="13889"> <Tier>Employee Only</Tier> <DeductionFrequency>26</DeductionFrequency> <EmployeeCost>7.6600</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>7.6600</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmountFrequency>0</BenefitAmountFrequency> <OptionCode /> <Description>Chubb Accident; EO</Description> <Section125>false</Section125> <InitialEffectiveDate>2017-12-01T00:00:00</InitialEffectiveDate> <EffectiveDate>2017-12-01T00:00:00</EffectiveDate> <PlanYearStartDate>2017-10-01T00:00:00</PlanYearStartDate> <FirstDeductionDate>2017-12-01T00:00:00</FirstDeductionDate> <EmployerFee>0.0000</EmployerFee> <EmployeeFee>0.0000</EmployeeFee> </Coverage> <Insureds> <Insured Age="30" ApplicantID="e47234e3-b058-4c4d-887a-3cc217b23c07" /> </Insureds> <Riders> <Rider> <Name>Yes</Name> <Code>EmployeeActivelyAtWork</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>SportsPackage</Name> <Code>SportsPackage</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>$1000</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Exclusion</Name> <Code>Exclusion</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>1.0000</BenefitAmount> <OptionCode>1</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Wellness</Name> <Code>Wellness</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>50.0000</BenefitAmount> <OptionCode>50</OptionCode> <IsFeature>true</IsFeature> </Rider> </Riders> <Beneficiaries> <Beneficiary UniqueID="00000000-0000-0000-0000-000000000000"> <Type>Primary</Type> <Name>Estate</Name> <Phone /> <BeneficiaryAddress> <FullAddress /> </BeneficiaryAddress> <Percent>100.0000</Percent> <FirstName /> <LastName /> <SSN /> <RelationshipDescription /> <CountryOfCitizenship /> </Beneficiary> </Beneficiaries> <Enrollers> <Enroller AgentID="3499"> <Number /> <Split>100</Split> </Enroller> </Enrollers> <ApplicationDate>2017-09-22T13:19:08</ApplicationDate> <Events> <Event EventClass="Added"> <UserID>3499</UserID> <EventDate>2017-09-22T10:50:32</EventDate> <ReasonCode>1</ReasonCode> </Event> </Events> <Locked>false</Locked> <PolicyNumber /> </Application> <Application ID="b6cfae83-b2bf-4f7a-bf20-8a3514b7db05" UniqueID="b6cfae83-b2bf-4f7a-bf20-8a3514b7db05" EmployeeID="e47234e3-b058-4c4d-887a-3cc217b23c07" ApplicantID="e47234e3-b058-4c4d-887a-3cc217b23c07" IncreaseEffectiveImmediate="false" ShowErrorMessages="false" Status="Complete"> <AsOfDate>2017-09-25T07:26:13</AsOfDate> <OfferingID>17582</OfferingID> <Coverage ProductID="13830"> <Tier>Employee Only</Tier> <DeductionFrequency>26</DeductionFrequency> <EmployeeCost>8.9400</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>8.9400</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>20000.0000</BenefitAmount> <BenefitAmountFrequency>0</BenefitAmountFrequency> <OptionCode /> <Description>Chubb Critical Illness; EO</Description> <Section125>false</Section125> <InitialEffectiveDate>2017-12-01T00:00:00</InitialEffectiveDate> <EffectiveDate>2017-12-01T00:00:00</EffectiveDate> <PlanYearStartDate>2017-10-01T00:00:00</PlanYearStartDate> <FirstDeductionDate>2017-12-01T00:00:00</FirstDeductionDate> <EmployerFee>0.0000</EmployerFee> <EmployeeFee>0.0000</EmployeeFee> </Coverage> <Insureds> <Insured Age="30" ApplicantID="e47234e3-b058-4c4d-887a-3cc217b23c07" /> </Insureds> <Riders> <Rider> <Name>Branding</Name> <Code>Branding</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Chubb</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Yes</Name> <Code>EmployeeActivelyAtWork</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>TB</Name> <Code>EmployeeTobacco</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>TB</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>IsValid</Name> <Code>IsValid</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Tobacco</Name> <Code>Tobacco</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>TB</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>PEGI_Control</Name> <Code>PEGI_Control</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>EEGILimit</Name> <Code>EEGILimit</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>10000.0000</BenefitAmount> <OptionCode>10000</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>PreexisitingCondition</Name> <Code>PreexisitingCondition</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>12.0000</BenefitAmount> <OptionCode>12</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>BenignBrainTumor</Name> <Code>BenignBrainTumor</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Cancer</Name> <Code>Cancer</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Coma</Name> <Code>Coma</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>HeartAttack</Name> <Code>HeartAttack</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>EndStageRenalFailure</Name> <Code>EndStageRenalFailure</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>MajorOrganFailure</Name> <Code>MajorOrganFailure</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Stroke</Name> <Code>Stroke</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Alzheimers</Name> <Code>Alzheimers</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>ParalysisorDismemberment</Name> <Code>ParalysisorDismemberment</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Burns</Name> <Code>Burns</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>ALS</Name> <Code>ALS</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>SSH</Name> <Code>SSH</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>MS</Name> <Code>MS</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Parkinsons</Name> <Code>Parkinsons</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>HIVHepatitis</Name> <Code>HIVHepatitis</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>ChildhoodConditions</Name> <Code>ChildhoodConditions</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>CoronaryArtery</Name> <Code>CoronaryArtery</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>SkinCancer</Name> <Code>SkinCancer</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>CarcinomaInSitu</Name> <Code>CarcinomaInSitu</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>AutoBenefit_Increase</Name> <Code>AutoBenefit_Increase</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>HospitalAdmission</Name> <Code>HospitalAdmission</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>500.0000</BenefitAmount> <OptionCode>500</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>MortgageHelp</Name> <Code>MortgageHelp</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>500.0000</BenefitAmount> <OptionCode>500</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>FamilyCare</Name> <Code>FamilyCare</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Wellness</Name> <Code>Wellness</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>25.0000</BenefitAmount> <OptionCode>25</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>CancerTreatment</Name> <Code>CancerTreatment</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>WaiverOfPremium</Name> <Code>WaiverOfPremium</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>Compsych</Name> <Code>Compsych</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>BestDoctors</Name> <Code>BestDoctors</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>Yes</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>SpouseMaxBenefit</Name> <Code>SpouseMaxBenefit</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>50.0000</BenefitAmount> <OptionCode>50</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>ChildMaxBenefit</Name> <Code>ChildMaxBenefit</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>25.0000</BenefitAmount> <OptionCode>25</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>BenefitReductionAt70</Name> <Code>BenefitReductionAt70</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <OptionCode>No</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>MaxBenefitAmount</Name> <Code>MaxBenefitAmount</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>3.0000</BenefitAmount> <OptionCode>3</OptionCode> <IsFeature>true</IsFeature> </Rider> <Rider> <Name>RecurrenceBenefit</Name> <Code>RecurrenceBenefit</Code> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmount>1.0000</BenefitAmount> <OptionCode>1</OptionCode> <IsFeature>true</IsFeature> </Rider> </Riders> <Beneficiaries> <Beneficiary UniqueID="00000000-0000-0000-0000-000000000000"> <Type>Primary</Type> <Name>Estate</Name> <Phone /> <BeneficiaryAddress> <FullAddress /> </BeneficiaryAddress> <Percent>50.0000</Percent> <FirstName /> <LastName /> <SSN /> <RelationshipDescription /> <CountryOfCitizenship /> </Beneficiary> <Beneficiary UniqueID="00000000-0000-0000-0000-000000000000"> <Type>Primary</Type> <Name>All Living Children</Name> <Phone /> <BeneficiaryAddress> <FullAddress /> </BeneficiaryAddress> <Percent>50.0000</Percent> <FirstName /> <LastName /> <SSN /> <RelationshipDescription /> <CountryOfCitizenship /> </Beneficiary> </Beneficiaries> <Enrollers> <Enroller AgentID="3499"> <Number /> <Split>100</Split> </Enroller> </Enrollers> <ApplicationDate>2017-09-25T02:26:13</ApplicationDate> <Events> <Event EventClass="Added"> <UserID>3499</UserID> <EventDate>2017-09-25T07:26:13</EventDate> <ReasonCode>1</ReasonCode> </Event> </Events> <Locked>false</Locked> <PolicyNumber /> </Application> </Applications> <TransmittalResult Status="OK" /> </Transmittal>