Chubb Enrollment Quoting and Enrollment Step 1 of 4 25% Hiddengroup Are you a ?* Yes No We are sorry, but you must be a customer to enroll for this insuranceBenefit Amount*Accidental Death Benefit $3,000$10,000$25,000$50,000$75,000$100,000$150,000$200,000$250,000$300,000Coverage* Customer Family State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingBirth Date* Month Day Year HiddenAge HiddenNot 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 AmountA $.95 administrative fee will be added each month for automatic account billing.HiddenBenefit AmountQuarterly Premium AmountA $.95 administrative fee will be added each month for automatic account billing.HiddenSemi AnnualHiddenAnnualHiddenForm PremiumHiddenGWKey Email* Enter Email Confirm Email PhoneName* First Last Gender Female Male Street Address* Address Line 2 City* State* Zip Code* Spouse First Last Spouse Birth Date* Month Day Year Child 1 First Last Birth Date* Month Day Year Gender*MaleFemaleChild 2 First Last Please leave blank if there are no additional children.Birth Date* Month Day Year Gender*MaleFemaleChild 3 First Last Please leave blank if there are no additional children.Birth Date* Month Day Year Gender*MaleFemaleChild 4 First Last Please leave blank if there are no additional children.Birth Date* Month Day Year Gender*MaleFemaleChild 5 First Last Please leave blank if there are no additional children.Birth Date* Month Day Year Gender*MaleFemaleChild 6 First Last Please leave blank if there are no additional children.Birth Date* Month Day Year Gender*MaleFemale If no beneficiary is on record, benefits will be paid per the “Beneficiary Death Benefit” provision as outlined in your Certificate of Insurance.Beneficiary First Last Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Relationship* HiddenPercentage*Please enter a number from 0 to 100.Consent I agree to the privacy policy. Card /ACH Payment: I authorize ias ( to charge my credit/debit card/ACH for the monthly amount due. The charge will appear as 1-833-241-2372 INS on my statement. This authorization will remain in effect until ias has received written notice from you that it should be cancelled. I further affirm that the name and personal information provided on this form are true and correct. I further declare that I understand and accept ias’s terms and conditions. I have read, understand and agree to the terms and conditions of the Group Accidental Death and Dismemberment insurance, including the limitations and exclusions, found in the Description of Coverage. I understand that benefits will be paid up to the maximum benefit limits. This information is a brief description of the important features of this insurance plan. It is not an insurance contract. Insurance benefits are underwritten by Federal Insurance Company. Coverage may not be available in all states or certain terms may be different where required by state law. Chubb NA is the U.S.-based operating division of the Chubb Group of Companies, headed by Chubb Ltd. (NYSE:CB) Insurance products and services are provided by Chubb Insurance underwriting companies and not by the parent company itself. 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. Notice to Arkansas, Louisiana, Maryland, Minnesota, New Mexico and Ohio Applicants: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false, fraudulent or deceptive statement is, or may be found to be, guilty of insurance fraud, which is a crime, and may be subject to civil fines and criminal penalties. Notice to Colorado Applicants: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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. Notice to District of Columbia: 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. Notice to Maine, Tennessee and Virginia Applicants: 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 or a denial of insurance benefits. Notice to Florida and Oklahoma Applicants: Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of: a felony (in Oklahoma) or a felony of the third degree (in Florida). Notice to Kentucky Applicants: Any person who, knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act which is a crime. Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Notice to Oregon and Texas Applicants: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. Notice to New York and Pennsylvania Applicants: 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 shall also be subject to: a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation (in New York) or criminal and civil penalties (in Pennsylvania). Notice to Washington Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the Company. Penalties include imprisonment, fines and denial of insurance benefits. Notice to Alabama Applicants: 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. Notice to West Virginia Applicants: 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. E-Consent*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). I AGREEEmailThis field is for validation purposes and should be left unchanged. All coverage amounts reduce by 50% at age 70.
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