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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:

FRAUD WARNING 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.

DECLARATIONS AND SIGNATURE

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
NOT A DEPOSITNOT INSURED BY ANY FEDERAL GOVERNMENT AGENCY
NOT FDIC INSUREDNOT GUARANTEED BY THE BANK

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Your legal name

Your email address

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Timestamp

Audit

April 8, 2019 1:30 pm CDT

Activation & Enrollment Form Uploaded by Scott Allison - allisons@driasi.com IP 136.228.217.166, 136.228.217.166

June 28, 2022 3:02 pm CDT

Document owner allisons@driasi.com has handed over this document to kohrsj@driasi.com 2022-06-28 15:02:05 - 136.228.217.166, 136.228.217.166