Activation & Enrollment Form


To activate your policy, please sign below and provide payment information on the following page.

 

 

 

Request for Insurance From:
Liberty Insurance Underwriters Inc. 175 Berkeley Street, Boston, MA 02116
Activation Form for Group Accidental Death and Dismemberment Insurance

Name:



,

Coverage Selected:  

Amount Selected:
(Insurance Benefit reduces by 50% at age 70 and by 75% at age 75.)

Date of Birth:    Gender:  

Email Address:

Beneficiary Information:
(If no beneficiary is on record, benefits will be paid per the “Beneficiary Death Benefit” provision as outlined in your Certificate of Insurance.)

Relationship:
Name:

 

Before signing this enrollment form, please read the warning for the state where the contract under which you are applying for coverage was issued.
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.

I hereby enroll for the Group Accidental Death and Dismemberment Policy issued by Liberty Insurance Underwriters Inc. I understand that to enroll for the insurance being offered, I must have an account with BBVA. I authorize the premiums due to be remitted monthly to Liberty Insurance Underwriters or its designee using payment information I have provided. This authority is to remain in effect until I cancel it by written notification to the administrator at least 30 days in advance of the intended date of cancellation. *A $.95 administrative fee will be added each month for automatic account billing. I hereby acknowledge that I have read and understand the exclusions and limitations of this program and the boxed disclosure, which appears on this form.

THIS INSURANCE PRODUCT IS

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Group Accidental Death and Dismemberment Insurance https://enroll.insadm.com
Signature Certificate
Document name: Activation & Enrollment Form
lock iconUnique Document ID: 2a0c245e75c4df9f319b16e22e05d18b1ad8301c
Timestamp Audit
April 8, 2019 1:30 pm CSTActivation & Enrollment Form Uploaded by Scott Allison - allisons@driasi.com IP 138.210.89.94, 138.210.89.94