Chubb – AD Enrollment – Group Accidental Death and Dismemberment Insurance

Chubb AD&D Enrollment

Quoting and Enrollment

Step 1 of 4

This field is hidden when viewing the form
group
Are you a ?*
- Yes
- No
We are sorry, but you must be a customer to enroll for this insurance
Select your benefit amount*
Accidental Death & Dismemberment Benefit
Coverage*
- Customer
- Family
If family coverage is selected, your dependents will be covered at a percentage of your benefit amount.
State*
Birth Date*
Month
Day
Year

This field is hidden when viewing the form
Age
This field is hidden when viewing the form
Not Eligible
We are sorry, but you are too young to apply for this coverage
We are sorry, but you are too old to apply for this coverage
We are sorry, this product is not currently available in this state.
Monthly Premium Amount
A $.95 administrative fee will be added each month for automatic account billing.
This field is hidden when viewing the form
Benefit Amount
Quarterly Premium Amount
A $.95 administrative fee will be added each month for automatic account billing.
This field is hidden when viewing the form
Semi Annual
This field is hidden when viewing the form
Annual
This field is hidden when viewing the form
Form Premium
This field is hidden when viewing the form
GWKey
Email*
Enter Email Confirm Email
Phone
Name*
First Last
Gender
- Female
- Male
Address
Street Address Address Line 2 City State Zip Code
This field is hidden when viewing the form
Street Address
This field is hidden when viewing the form
Address Line 2
This field is hidden when viewing the form
City
This field is hidden when viewing the form
State
This field is hidden when viewing the form
Zip Code

Spouse
First Last
Spouse Birth Date*
Month
Day
Year
Child 1
First Last
Birth Date*
Month
Day
Year
Gender*
Child 2
First Last
Please leave blank if there are no additional children.
Birth Date*
Month
Day
Year
Gender*
Child 3
First Last
Please leave blank if there are no additional children.
Birth Date*
Month
Day
Year
Gender*
Child 4
First Last
Please leave blank if there are no additional children.
Birth Date*
Month
Day
Year
Gender*
Child 5
First Last
Please leave blank if there are no additional children.
Birth Date*
Month
Day
Year
Gender*
Child 6
First Last
Please leave blank if there are no additional children.
Birth Date*
Month
Day
Year
Gender*

Monthly Premium
Beneficiary
First Last
Address
Street Address Address Line 2 City State ZIP Code
Relationship*
This field is hidden when viewing the form
Percentage*
Please enter a number from 0 to 100.
This field is hidden when viewing the form
Not Eligable
We are sorry, this product is not currently available in this state.
If no beneficiary is on record, benefits will be paid per the “BENEFICIARY PROVISIONS” as outlined in your Certificate of Insurance.
Consent
I agree to the privacy policy.

Privacy Statement

Protecting your private information is our priority. This Statement of Privacy applies to https://enroll.insadm.com and Direct Response Insurance Administrative Services Inc (driasi) and governs data collections and usage for the purpose of this Privacy Policy, unless otherwise noted, all references to Direct Response Insurance Administrative Services Inc include https://enroll.insadm.com. The driasi website is an Accidental Death and Dismemberment Insurance enrollment site. By using the driasi website, you consent to the data practices described in this statement.

Collection of your Personal Information

In order to better provide you with products and services offered, driasi may collect personally identifiable information, such as your:

· First and Last Name
· Mailing Address
· E-mail Address
· Phone Number
· Date of Birth
· Gender

If you purchase driasi’s products and services, we collect billing and credit card information. This information is used to complete the purchase and is not shared with any third-party entities.

We do not collect any personal information about you unless you voluntarily provide it to us.

Use of your Personal Information

driasi collects and uses your personal information to operate and deliver the services you have requested.

driasi may also use your personally identifiable information to inform you of other products or services available from driasi and its affiliates.

Sharing Information with Third Parties

driasi does not sell, rent, or lease it’s customer lists to third parties. Although it may be shared with the carrier to properly administer your policy.

driasi may disclose your personal information without notice, if required to do so by law or in the good faith belief that such action is necessary to (a) conform to the edicts of the law or comply with legal process served on driasi or the site; (b) protect and defend the rights or property of driasi: and/or (c) act under exigent circumstances to protect the personal safety of users of driasi, or the public.

Automatically Collected Information

Information about your computer hardware and software may be automatically collected by driasi. This information can include your IP address, browser type, domain names, access times and referring website addresses. This information is used for the operation of the service, to maintain quality of the services, and to provide general statistics regarding use of the driasi website.

External Data Storage Sites

We may store your data on servers provided by third party hosting vendors with whom we have contracted.

Change to this Statement

driasi reserves the right to change this Privacy Policy from time to time.

Contact Information

driasi welcomes your questions or comments regarding this Statement of Privacy. If you believe that driasi has not adhered to this Statement, please contact driasi at:

Direct Response Insurance Administrative Services Inc
7930 Century Boulevard
Chanhassen MN 55318

Email Address
customerservice@driasi.com

Toll Free
1-833-241-2372
E-Consent*
I AGREE
STATEMENT ON CONSUMER CONSENT TO THE USE OF ELECTRONIC TRANSACTIONS, SIGNATURES AND RECORDS (Consent Statement)

In this Agreement, "we," "us," "our," and "the company" refer to Federal Insurance Company, member insurer of the Chubb Group of Insurance Companies Insurance. "You" and "yours" refer to the applicant for a policy offered by us.

1. Consent to do business with, and receive communications from Federal Insurance Company electronically. To the extent permitted by law, this Agreement is a "global" consent. You agree to:
a) Complete transactions electronically and use electronic signatures on a website we make available to you.
b) As applicable, allow us to replace paper delivery with electronic delivery of your documents and communications relating to policies you own or are applying for. Electronic delivery of the documents will be by e-mails transmitting such documents, whether as text in, attachments to, and/or hyperlinks from such e-mails to the documents stored on a Chubb website or a third party’s website. You specifically agree that delivery of the link to your policy constitutes delivery of the policy and starts the free look period under your policy.
c) As applicable, receive text messages with important updates on your application and policy. You agree to allow us to send text messages to the mobile number you provide. You understand that standard message and data rates apply.
d) Make sure that neither your software nor your internet service provider inhibits or interferes with your receipt of electronic communications from us. Update your electronic mail address when it changes.
Note: You’ll continue to receive paper copies of certain documents until the electronic versions become available.
2. Withdrawal of consent. You can easily withdraw your consent at any time by calling ias at 1-833-241-2372 or emailing to: customerservicegeneral@driasi.com.

3. Effect of not consenting or withdrawing consent. If you choose not to consent or to withdraw your consent, you can still submit an application by signing a paper copy of the application.

4. How to obtain paper copies of the documents you sign electronically by calling ias at 1-833-241-2372 or emailing to: customerservicegeneral@driasi.com.

5. Hardware requirements. To use this service, you must have access to a computer with an Internet connection. If you would like to be able to save the documents that you receive, the computer should have a hard drive or other storage device or be connected to a printer. You must also have an email account to receive communications.

6. Software Requirements. In order to complete the electronic signature process and to download your application, you will need Adobe Acrobat Reader 3.0 (or greater).
Email
This field is for validation purposes and should be left unchanged.

All coverage amounts reduce by 50% at age 70.

*Indicates required fields