Enrollment Form For Group Life Insurance Page 2
Download a blank fillable Enrollment Form For Group Life Insurance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Enrollment Form For Group Life Insurance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2AGENT/PRODUCER SPLIT DESIGNATION: Please list any agents not included in the AGENT/PRODUCER’S STATEMENT section.
Agent/Producer listed in AGENT/PRODUCER’S STATEMENT % _______
_____________________________________ _____________________________________________ _______________________________ ______
Additional Agent/Producer Signature
Additional Agent/Producer Name Printed
Additional NGL Agent/Producer #
%
ACKNOWLEDGMENT OF PAYMENT: This acknowledges payment from __________________________________ in the amount of
$ _________________ in connection with the Policy applied for from NGL. If all of the conditions of the application are met and the
application is accepted, a Policy will be issued. If the application is not accepted, the Insurer’s only responsibility will be to refund the
amount for which this Acknowledgment of Payment was given.
ELECTRONIC CHECK DISCLOSURE: When you provide a check as payment, you authorize us to either use information from your check
to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use
information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day
you make your payment, and you will not receive your check back from your financial institution. In the event that the payment is not
honored, NGL has the right to re-present the transaction. For inquiries please call 1-800-762-9883.
FRAUD WARNING STATEMENTS
For Residents of Washington: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a
false statement in an application for insurance may be guilty of a criminal offense under state law. Penalties include imprisonment, fines and
denial of coverage.
“Policy” is defined as the insurance policy or certificate for which I am applying.
2735FE-WA 06/11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business