Secure Life Plan Form – Fill Out and Use This PDF

IAC PERSONAL HEALTH PLANS BENEFIT SELECTION FORM

Underwritten by Fidelity Security Life Insurance Company, Kansas City, Missouri			CASE NUMBER _______________________
APPLICANT'S NAME				SOCIAL SECURITY NUMBER
____________________________________________________________________				___________________________
(LAST)	(FIRST)	(INITIAL)

PLAN SELECTION: Design your plan by selecting your In-Network plan options. Out-of-Network benefits differ from In- Network benefits and are based on your selections below. See the product brochure for details.

ˆ Deluxe Plan	ˆ Advantage Plan	ˆ Value Plan	ˆ High Deductible Plan			ˆ Daily Plan
Deductible:	Deductible:	Deductible:	Deductible:			Daily Deductible
ˆ $1,000	ˆ $1,000	ˆ $2,500	Single	Family		ˆ $250
ˆ $1,500	ˆ $2,000	ˆ $3,500	ˆ $2,000 ˆ $4,000			ˆ $500
ˆ $2,500	ˆ $3,000	ˆ $4,500	ˆ $2,700 ˆ $5,450
	ˆ $4,000
ˆ $3,500		ˆ $5,500	ˆ $3,000*		ˆ $6,000*
	ˆ $5,000
ˆ $4,500		ˆ $7,500	ˆ $4,000*		ˆ $8,000*
	ˆ $10,000
ˆ $5,500		ˆ $10,000	ˆ $5,250* ˆ $10,500*
			*Available only if 100% Coinsurance Option is
Maximum out-of-			selected.
pocket options:
ˆ $2,000			Coinsurance Options:
ˆ $4,000			ˆ 100%
			ˆ 80%

HSA Enhancement

ˆIAC’s HSA

ˆOwn HSA (Submit attestation of HSA form)

ˆNo HSA

Preferred Provider Organization (PPO) Network Selected:

Optional Benefits

	Outpatient Prescription Drug	ˆ Deductible & Coinsurance (Not available on the Daily Plan)			ˆ Default Rx Option
	Coverage	Outpatient Rx covered the same as any other illness.			ˆ High Deductible Plan Only – Discount
	18-Month Rate Guarantee	ˆ Yes ˆ No (12-Month Rate Guarantee will apply if not elected)
	Wellness Coverage	ˆ Yes	ˆ No ˆ Texas Mandated Wellness only
	Supplemental Accident	ˆ $500	ˆ $1,000
	Vision Coverage	ˆ Option 1- $10 Exams / $25 Lenses ˆ Option 2- $20 Exams / $20 Lenses
	Available only in CO, IL, MO, NE,
	NV, NM, OH, OK, TN, VA, & WV
	24-hour Occupational Coverage	Sole proprietors, partners (ownership over 10%), or business owners not covered by Workers’ Compensation
		are eligible. Do you qualify for this benefit? (Verification may be necessary.)
	Automatically included in FL
		Applicant: ˆ Yes		ˆ No
		Spouse:	ˆ Yes	ˆ No

Attach this form to your Fidelity Security Life Insurance Company Application for Insurance

		For Administrative Use Only					Other:
Case Number	Enter	Date	Approved By	Date	Eff Date	PCEFDT
_____________	__________	_________	_____________	___________	__________	________

IAC Personal Health Plans Plan Selection Form 3-14-07

FIDELITY SECURITY LIFE INSURANCE COMPANY

APPLICATION FOR INSURANCE

Underwritten by Fidelity Security Life Insurance Company, Kansas City, MissouriCASE NUMBER __________________

ATTENTION PRODUCER: Where do you want the Certificate of Coverage mailed? (Check one) Producer _______ Insured _______

GENERAL INFORMATION

Applicant Information (Please print in blue or black ink)

Applicant's Name

Social Security Number

____________________________________________________________________________________

__________________________________

(Last)

(First)

(Initial)

Applicant’s Home Address

__________________________________________________________________________________________________________

Street

City

State

Zip Code

Billing Address

E-MAIL ADDRESS

________________________________________________________________________________________

_____________________________

Street

City

State

Zip Code

Home Telephone Number

Work Telephone Number

Fax Number

Best Time For Us To Call

___________________________

__________________________

_____________________

(Hm) _______ (Wk) _______

Occupation (Title & Industry)

Status:

Male

Female

Birthdate

Age

Height

Weight

__________________________________

Single

Married

___/____/______

_____

___ Ft ___ In

_____ Lbs

Title

Industry

Dependent Information (Complete only for dependents to be covered under this plan)

Spouse’s Name

Social Security Number

____________________________________________________________________________________

_____________________________

(Last)

(First)

(Initial)

Spouse’s Occupation (Title & Industry)

Height

Weight

Birthdate

Age

___ Ft ___ In

_____ Lbs

Dependent’s Name (First and Last)

Relationship

Sex

Birthdate

Height

Weight

Full-time Student?

___/____/______

___ Ft ___ In

_____ Lbs

ˆYes ˆNo

___/____/______

___ Ft ___ In

_____ Lbs

ˆYes ˆNo

___/____/______

___ Ft ___ In

_____ Lbs

ˆYes ˆNo

___/____/______

___ Ft ___ In

_____ Lbs

ˆYes ˆNo

___/____/______

___ Ft ___ In

_____ Lbs

ˆYes ˆNo

___/____/______

___ Ft ___ In

_____ Lbs

ˆYes ˆNo

___/____/______

___ Ft ___ In

_____ Lbs

ˆYes ˆNo

Has the Applicant or Spouse (if applying for coverage) used tobacco or tobacco cessation products during the past 12 months?

Applicant: ˆ No ˆ Yes – indicate types of tobacco/cessation products and the frequency of usage: _________________________________________

Spouse: ˆ No ˆ Yes – indicate types of tobacco/cessation products and the frequency of usage: _________________________________________

Requested Effective Date (check one):

ˆ I request the Company assign my effective date to be the 1st of the month following approval.

ˆ I request an effective date of ____________________ (must be the 1st or 15th of the month). I understand I cannot change this date.

If the Company is unable to approve the application within 60 days of the application date, the requested effective date will not be honored and a new, currently dated application may be required.

Mode of Payment: ˆ Direct Bill: Select ˆ Monthly ˆ Quarterly or ˆ Semi-annually. Submit check for first premium payment with this application.

ˆ Credit Card* ˆ Bank Draft*	ˆ Monthly List Bill
*Drawn monthly only. Complete the IAC Monthly Automatic Payment Plan page.
Who is to be insured? (Check all that apply)	ˆ Applicant	ˆ Spouse	ˆ Child(ren)
Other Coverage (Must be completed for the application to be processed.)
Are you or any dependents replacing other health insurance coverage?		ˆ Yes ˆ No	If yes, please provide the following information:

Carrier Name: ___________________________________ Policy No. ____________________ Effec. Date: _________ Termination Date: _________

Was this an employer-sponsored group health plan? ˆ Yes ˆ No

Is it your intent to be considered under HIPAA provisions? ˆ Yes ˆ No If yes, you must complete the HIPAA eligibility section of this application and attach the Certificate of Creditable Coverage you have received from your Employer.

A00894 CP

Gnl FSL App (11-1-06a)

PREFERRED UNDERWRITING CLASSIFICATION

INSTRUCTIONS: You may qualify for a Preferred Rating Classification depending on your health history and risk-avoidance behavior. Any applicants applying for coverage with the intent to obtain a Preferred Rate:

a.Must be the proposed primary insured and/or spouse. Preferred Rates are not available for dependent children;

b.Must be age 18 or older, but not older than age 50;

c.Must not have a condition that would result in a health exclusion rider or health rate-up at any level of benefit for the plan; and

d.Must answer “No” to questions 1-7 below. If age 40 or older, must also answer “Yes” to question 8 and provide the requested information. The following questions must be answered by each person proposed for insurance (Proposed Insured and the Proposed Insured’s spouse, if applicable) to determine his or her eligibility for Preferred Rates.

Primary

Applicant

Spouse

Question

ˆ Yes ˆNo

ˆ Yes ˆNo

1.

Have you been advised by a medical professional that you have blood pressure in excess of 130/85 (more

than 130 systolic and/or more than 85 diastolic) or have you been treated for high blood pressure within the

ˆ Yes

ˆNo

ˆ Yes

ˆNo

2.

Have you been advised by a medical professional that you have a total cholesterol reading above 200 or

have you been treated for elevated cholesterol or triglycerides within the past 12 months?

ˆ Yes ˆNo

ˆ Yes ˆNo

3.

Have you had any convictions for DUI or DWI or have you had more than 2 moving violations within the past

2 years?

ˆ Yes

ˆNo

ˆ Yes

ˆNo

4.

Have you used tobacco in any form or any nicotine products at any time during the past 2 years?

ˆ Yes

ˆNo

ˆ Yes

ˆNo

5. Are you currently outside the weight range shown on the Build Chart for Preferred Risks?

Male

Female

Height

Weight

Height

Weight

Height

Weight

Height

Weight

5'0"

105-152

5'9"

131-191

4'10"

90-128

5'7"

112-160

5'1"

110-155

5'10"

134-197

4'11"

92-130

5'8"

115-165

5'2"

113-159

5'11"

138-203

5'0"

94-133

5'9"

118-172

5'3"

115-162

6'0"

142-208

5'1"

96-136

5'10"

122-178

5'4"

117-166

6'1"

147-215

5'2"

98-140

5'11"

125-183

5'5"

120-171

6'2"

153-220

5'3"

101-143

6'0"

129-188

5'6"

122-175

6'3"

158-226

5'4"

104-147

6'1"

132-192

5'7"

125-181

6'4"

163-232

5'5"

107-151

6'2"

135-198

5'8"

128-186

6'5"

169-240

5'6"

109-156

6'3"

138-204

ˆ Yes

ˆNo

ˆ Yes

ˆNo

6.

Are you currently taking any prescription medication other than those used for acute medical conditions such

as antibiotics or for those used for non-medical conditions such as birth-control?

ˆ Yes

ˆNo

ˆ Yes

ˆNo

7.

Has it been more than 90 days since you had major medical coverage (group or individual) in force?

ˆ Under age 40

ˆ Under age 40

8.

If age 40 or older, have you had a physical exam by a licensed physician that included an evaluation of your

ˆ Yes

ˆNo

ˆ Yes

ˆNo

build, blood pressure, and cholesterol in the past 3 years?

___________________________

________________________________

_________________

Physician Name

Physician Address

Date of Exam

Note: Information we gather during the application process about medical conditions, avocations, or medications you are taking may prevent you from qualifying for preferred rates.

My answers are true and complete. I represent that to the best of my knowledge and belief all of the statements and answers on this questionnaire are complete and true. I understand that the information provided herein along with the application and any amendments will be the basis for this contract. I understand and agree that this questionnaire is a part of the application for health/medical insurance coverage with Fidelity Security Life Insurance Company.

I attest that the information provided above is true, complete and correct

______________________________________________________________________________________________________________________

Name of Applicant or parent, if applicant is under age 18 (print)Name of Spouse if applying for coverage (print) Date

______________________________________________________________________________________________________________________

Signature of Applicant or parent, if applicant is under age 18Signature of Spouse if applying for coverageDate

______________________________________________________________________________________________________________________

Name of licensed producer

Signature of licensed producer

Date

A00894 CP

Gnl FSL App (11-1-06a)

EVIDENCE OF INSURABILITY

ˆYes 1. Have you or any eligible dependent ever been declined, postponed, ridered, or rated up for medical, disability, or life insurance with another

ˆ No	insurance carrier? If yes, please indicate the action and explain:

ˆYes 2. Is any person to be insured receiving treatment, taking medication, or been advised of a condition that will require medical attention or to

ˆ No	have medical test(s)? If yes, list names and provide details in the Health History section on the following page.

ˆYes 3. Have you or any of your eligible dependents received disability benefits? If yes, list names and type of coverage:

ˆNo

	ˆ Yes	4. Has any person to be insured ever been diagnosed or tested positive for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related
	ˆ No
		Complex by a Physician or member of the medical profession? If yes, list names:

ˆYes 5. Has anyone to be insured had breast implants, pin, plate, or other implants? If yes, list names and provide details on the following page.

ˆNo

ˆYes 6. Have you had any convictions for reckless driving or driving under the influence of alcohol or drugs? If yes, list name, violation(s) and date(s)

ˆ No	of occurrence in the Health History section on the following page.

ˆYes 7. In the past 5 years, have you or any eligible dependent engaged in, or plan to engage in, any hazardous sport including, but not limited to:

ˆ No	scuba diving, rodeo activities, skydiving or auto, motorcycle or motor boat racing? If yes, please explain on the following page.

ˆYes 8. Are you, your spouse, or any dependents now pregnant or an expectant parent, whether applying for coverage or not? If yes, list names and

ˆ No	provide details in the Health History section on the following page.

ˆYes 9. Are you or your dependents currently taking or have you been prescribed medications within the past 12 months? List details/medications

ˆ No	on the following page.

ˆYes 10. Have you or your dependents previously applied for coverage with Insurers Administrative Corporation?

ˆ No	If yes, list the policy number: _________________________

ˆYes 11. Have you or your dependents been hospitalized within the last 7 years? If yes, list names and provide details on the following page.

ˆNo

12.Within the past seven years, has any person to be insured had any symptoms, diagnosis, consultation, treatment, or taken any medication or received counseling for (MARK ALL THAT APPLY):

Abnormal Test Results			Eye Disorders			Neurological Disease
Alcoholism/Alcohol Abuse			Fractures/Dislocations			Pap Smear, Abnormal
Allergies			Gallbladder Disorder			Paralysis
Arthritis or Rheumatism			Headaches/Migraine			Prostate/Rectal Disorder
Asthma/Respiratory Disorder			Heart Disorder/Murmur/Heart			Reproductive Organs
			Attack/Coronary Artery Disease			Disorder/Endometriosis
Back/Muscle or Joint Disorder			Hepatitis: Aˆ Bˆ Cˆ			Sexually Transmitted Diseases
Bladder Disorder			Hernia			Sinus Disorder
Blood Disorder/Hemophilia			High Blood Pressure/Hypertension			Skin Disorder
Bone Disease/Deformity			High Cholesterol			Sleep Disorders
Breast Disorder/Fibrocystic Breast			Infertility Testing/Treatment			Spinal Disorder/Back/Neck Strain
Disease
Cancer			Kidney Disorder			Stroke
Colitis, Spastic Colon, Polyps			Liver Disorder			Thyroid or Goiter
Congenital Disorder			Lupus/Systemic or Discoid			Transplants
Cystic Fibrosis			Lymphadenopathy/Immune Disorder			Tuberculosis
Diabetes/Pancreatic Disorders			Menstrual Disorder			Tumors/Cysts/Polyps/Growths
Digestive Disorder/Reflux			Mental, Nervous, Emotional Disorder /			Ulcerative Colitis/Crohn's/
			Anxiety/Depression/Attention Deficit Disorder			Regional Ileitis
Drug Addiction			Mental Retardation			Ulcers
Ear/Throat Disorders			Down's Syndrome			Urinary Tract Disorder
Eating Disorder/Anorexia/ Bulimia			Muscular Dystrophy			Vascular Disorder
Emphysema/Lung Disorder/COPD			Cerebral Palsy			Other conditions
Epilepsy and/or Seizure			Brain or Nerve Disorder

If you answered yes to any of the above conditions, list the condition and provide details in the Health History section on the following page.

I attest that the information provided above is true, complete and correct

___________________________________________________________________________________________________________________________________________________

Name of Applicant or parent, if applicant is under age 18 (print)Name of Spouse if applying for coverage (print) Date

___________________________________________________________________________________________________________________________________________________

Signature of Applicant or parent, if applicant is under age 18

Signature of Spouse if applying for coverage

Date

A00894 CP

Gnl FSL App (11-1-06a)

HEALTH HISTORY

INSTRUCTIONS: Provide complete details to any question marked “Yes” in the Evidence of Insurability section in the space provided below. We may need to request additional information regarding your health history from you or your attending physician. If you need more space, please us the Health History Supplementary Form located at the end of this application.

LAST PHYSICIAN SEEN

INSTRUCTIONS: List your healthcare providers for the past 7 years in the space provided below.

____/____

____/____

____/____

____/____

____/____

MEDICATIONS CURRENTLY PRESCRIBED OR BEING USED

INSTRUCTIONS: List all medications prescribed or taken by you or your dependents currently and in the past 12 months.

____/____

____/____

____/____

____/____

____/____

I attest that the information provided above is true, complete and correct

______________________________________________________________________________________________________________________

Name of Applicant or parent, if applicant is under age 18 (print)Name of Spouse if applying for coverage (print) Date

______________________________________________________________________________________________________________________

Signature of Applicant or parent, if applicant is under age 18	Signature of Spouse if applying for coverage	Date
A00894 CP		Gnl FSL App (11-1-06aa)

Authorization for Release of Health-Related Information.

I authorize the disclosure of health information regarding, or related to the following individuals for whom an application for insurance has been submitted:

Print Name(s): (Last)	(First)	(MI)	Date of Birth (Month/Day/Year)
1				/	/
2				/	/
3				/	/
4				/	/
5				/	/
6				/	/

I authorize the disclosure of any and all information that: (i) is created or received by a health care provider, health plan including health insurer or health insurance agent, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (ii) relates to the past, present, or future physical or mental health or condition of an individual listed above; the provision of health care to an individual listed above; or the past, present, or future payment for the provision of health care to an individual listed above. This authorization permits the disclosure of all medical records including without limitation those containing information relating to diagnoses, treatments, consultation, care, advice, laboratory or diagnostic tests, physical examinations, recommendations for future care, and prescription drug information.

I specifically authorize the disclosure of information related to (i) communicable diseases, including HIV, AIDS or AIDS related complex (to the extent permitted by both state and federal law); (ii) drug and alcohol abuse and treatment; (iii) mental illness and treatment; and (iv) genetic conditions including genetic testing (to the extent permitted by both state and federal law). Notwithstanding the above, this authorization does not authorize the release of psychotherapy notes.

I authorize any and all health care providers including without limitation physicians, medical practitioners, hospitals, clinics, medical or medically-related facilities, pharmacy benefit managers, pharmacies or pharmacy-related facilities; and any and all health plans, insurance companies, insurance support organizations (such as MIB Group, Inc.), business associates of health plans or insurance companies and those persons or entities providing services to such business associates to disclose the information described above.

I authorize Fidelity Security Life Insurance Company (“FSL”), including its affiliated companies, subsidiaries and business associates, including those persons or entities providing services to its business associates, to receive the disclosure of information authorized herein and use the information disclosed pursuant to this authorization.

The purpose of the disclosure authorized herein is to permit FSL, including its affiliated companies, subsidiaries and business associates, including those persons or entities providing services to its business associates, to obtain and use the information described above to make prospective and retrospective eligibility, underwriting and risk rating determinations, including whether the individual is subject to a pre- existing condition exclusion.

This authorization shall expire twenty-four (24) months after the date on which it is executed below.

I understand that eligibility for the health plan is conditioned on my execution of this authorization for the use or disclosure of the information described above for the purpose of making eligibility, underwriting and risk rating determinations. Except as otherwise stated herein, treatment, payment, enrollment in a health plan, or eligibility for benefits is not conditioned on an authorization for the use or disclosure of the information described above.

I understand that I may revoke this authorization by sending written notice of my intent to revoke this authorization to P.O. Box 37587, Phoenix, AZ 85069, Attention Privacy Officer.

I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality.

A copy or facsimile of this authorization shall be as valid as the original.
Signature of each Individual over the age of 18 or the Individual’s Legal Representative:	Date:
X_______________________________________________________________________	___________________
X_______________________________________________________________________	___________________
X_______________________________________________________________________	___________________

If signed by the individual’s legal representative (e.g. a parent on behalf of a child), please describe the representative’s authority to sign on behalf of the individual:

Name:

Authority:

A00894 CP

Gnl FSL App (11-1-06a)

HEALTH HISTORY SUPPLEMENTAL FORM

INSTRUCTIONS: Provide complete details to any question marked “Yes” in the Evidence of Insurability section in the space provided below. We may need to request additional information regarding your health history from you or your attending physician. Attach as many of these Health History Supplemental Forms as necessary to provide complete information.

LAST PHYSICIAN SEEN

INSTRUCTIONS: List your healthcare providers for the past 7 years in the space provided below.

____/____

____/____

____/____

____/____

____/____

MEDICATIONS CURRENTLY PRESCRIBED OR BEING USED

INSTRUCTIONS: List all medications prescribed or taken by you or your dependents currently and in the past 12 months.

____/____

____/____

____/____

____/____

____/____

I attest that the information provided above is true, complete and correct

______________________________________________________________________________________________________________________

Name of Applicant or parent, if applicant is under age 18 (print)Name of Spouse if applying for coverage (print) Date

______________________________________________________________________________________________________________________

Signature of Applicant or parent, if applicant is under age 18

Signature of Spouse if applying for coverage

Date

A00894 CP

Gnl FSL App (11-1-06a)