Sample Enrollment – Group Accidental Death and Dismemberment Insurance

Sample AD&D Enrollment

Quoting and Enrollment

Step 1 of 4

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group
Are you a ?*
- Yes
- No
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customer_id
We are sorry, but you must be a customer to enroll for this insurance
Benefit Amount*
Accidental Death Benefit
Coverage*
- Individual
- Family
State*
Birth Date*
Month
Day
Year

Spouse
First Last
Spouse Birth Date*
MM slash DD slash YYYY
Child 1
First Last
Birth Date*
MM slash DD slash YYYY
Gender*
Child 2
First Last
Please leave blank if there are no additional children.
Birth Date*
MM slash DD slash YYYY
Gender*
Child 3
First Last
Please leave blank if there are no additional children.
Birth Date*
MM slash DD slash YYYY
Gender*
Child 4
First Last
Please leave blank if there are no additional children.
Birth Date*
MM slash DD slash YYYY
Gender*
Child 5
First Last
Please leave blank if there are no additional children.
Birth Date*
MM slash DD slash YYYY
Gender*
Child 6
First Last
Please leave blank if there are no additional children.
Birth Date*
MM slash DD slash YYYY
Gender*

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 ZIP Code
Relationship*
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Percentage*
Please enter a number from 0 to 100.
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 Liberty Mutual Insurance Company. "You" and "yours" refer to the applicant for a policy offered by us.

1. Consent to do business with, and receive communications from, Liberty Mutual 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 Liberty Mutual 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.

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.

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 AGREE
Phone
This field is for validation purposes and should be left unchanged.

Sample AD&D Enrollment

Step 1 of 4

STATEMENT ON CONSUMER CONSENT TO THE USE OF ELECTRONIC TRANSACTIONS, SIGNATURES AND RECORDS (Consent Statement)

STATEMENT ON CONSUMER CONSENT TO THE USE OF ELECTRONIC TRANSACTIONS, SIGNATURES AND
RECORDS
(Consent Statement)