Please review the information below and use the edit links provided to make any necessary changes or corrections. For further assistance, please contact your healthcare agent.
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The insurance described in this enrollment website provides limited benefits. Limited benefits plans are insurance products with reduced benefits and are not intended to be an alternative to or integrated with comprehensive coverage. Further, this insurance does not coordinate with any other insurance plan. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act. Plans are underwritten by First Continental Life and Accident Insurance Company and are not major medical insurance and are NOT designed to replace, provide, or modify major medical insurance. This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the policies issued in the state in which the policies are delivered. Complete details may be found in the policies on file at your association's office. The policies are subject to the laws of the state in which they are issued. Coverage may not be available in all states or certain terms may be different if required by state law. Please keep this information as a reference. First Continental Life and Accident Insurance Company assumes no responsibility or liability for non-insurance services of third parties. Standalone Accidental Death & Dismemberment insurance is underwritten by Lloyd's of London.
In addition to the insurance premium for the Limited-Benefit Medical Insurance products being offered, the total rate charged to you may include monthly fees for non-insurance products and services and $5.95 per month association dues. Association membership terms can be found on the association membership website at www.associationmembership.org. Please note that third party products and services are governed by separate terms and conditions that may be different. Products and services may be subject to change.
I agree that I have a full and complete understanding of the products for which I am applying. I certify that I am the applicant listed above and I elect to apply for the following products:
By electing a Colonial Life benefit, I am affirming that I have read and agree to the Colonial Life Disclosures, Limitations and Exclusions document located in the document resource center.
By electing a Paul Revere benefit, I am affirming that I have read and agree to the Paul Revere Disclosures, Limitations and Exclusions document located in the document resource center.
By clicking submit, I acknowledge that I have read, understand and agree to the terms of coverage, and that the insurance coverage elected is not traditional health insurance or major medical coverage, and it is not designed as a substitute for traditional health insurance or major medical coverage. In addition to the insurance premium for the limited benefit products being offered, I understand that the total rate charged includes monthly fees for non-insurance roducts and services and $5.95 per month association dues. I understand that I can cancel my association membership and insurance products on a future date, at any time by calling Association Services or by email at [email protected]
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I certify that the above information is correct. I authorize my group to make deductions from my earnings necessary to provide my contribution for this coverage and understand that my group is performing this service for my benefit and not as an agent of any insurer. I understand that coverage is not in force until the effective date shown on the Summary Plan Description issued to me. If this form is accepted, this request for participation in my group plan will become part of the agreement between Providence Insurance Partners, LLC and my group.
Fraud Notice - The following general Fraud Notice is intended to comply with the laws of your state. If any part of such language is found in conflict, such language shall be construed as amended to the extent necessary in order to meet the minimum requirements of your state. Any person who, knowingly and with intent to defraud or deceive any insurance company, files an application containing any materially false, incomplete or misleading information may be guilty of committing a fraudulent insurance act which is a crime and may be subject to criminal prosecution.
Based on the Agreement signed by your group with Providence Insurance Partners, LLC, the monthly rate for MECTM is as follows:
I have read and understand the above rates, one of which applies to my enrollment based on my enrollment and any additional spouse and/or dependent enrollment as noted in the rates.
If you have any questions regarding this document, please contact Member Services (Monday - Friday 8am to 6pm) at 866-995-5944.
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