Group Enrollment Processing
In order to ensure proper processing of your applications, please read the following instructions carefully.
1) Once you have selected the plan(s) in which you wish to enroll, print and complete thecorresponding application(s).
2) Make sure you have signed and completed the application(s) in their entirety. Check them forany errors or missing information.
3) Review, complete and sign the Automatic Deduction Agreement form.
4) Make a photocopy of your voided check for the account from which you would like the premiumdeduction to take place and include it with your forms. Remember, all bank account deductionswill take place on the 1st business day of each month. If we are unable to draft your account onthis day, you may be subject to fees as outlined in the Automatic Deduction Agreement.
5) Email your application with the Automatic Deduction Agreement and the voided check [email protected]. We MUST have all applications by the posted due date or coveragecannot become effective!
Please call us with any questions you have during the enrollment process.
Group InsuranceBenefi ts Administrator
P: (888) 564-0300, toll freeF: (856) 396-3193E: [email protected]
DergalisASSOCIATES
Email all finished paperwork to: [email protected]
Q: Must I take all of the benefits? A: No, each benefit can be purchased individually.
Q: Will I get another oppor tunity to enroll if I decline to take coverage now? A: Once a year, the Group Dental and Vision plans will have an Open Enrollment period. However, the Group
Disability and Life Insurance will NEVER be offered again on a Guaranteed-Issue basis. While you can apply at a later date, limited medical underwriting will be required and the carrier will have the right to decline you coverage based on the results.
Q: I currently have other coverage for Dental and Vision. If I lose that coverage, could I participate in your program?
A: Yes, you will have the oppor tunity to enroll in the Dental or Vision plan within 30 days of a qualifying life event such as birth, death, divorce or loss of coverage. For more information on what constitutes a qualifying life event, please contact our office.
Q: Is the Automatic Deduction from my checking account the only way to pay? A: Please contact our office at (888) 564-0300 for more information. Additionally, you can use a savings account
as long as you provide a deposit slip imprinted with your name, bank account number and bank routing number. Please note, we are not set up for individual billing and cannot accept a check as payment.
Q: When and how will I receive confirmation of my coverage? A: You should receive an email from our office within three weeks. Please make sure to check your junk mail
folder if you haven’t received the email.
Q: What if I have an emergency before I receive proof of coverage?A: In the event of an emergency situation, you should contact
Someone will help in the transition period.
Q: Why am I not receiving email communication from the group insurance
A: The domain agentbenefits.net may be filtered out by some e-mail providers as “SPAM”. Please ensure to update your email address and communication preferences.
Frequently Asked Questions
Group Insurance at (888) 564-0300.
department?
The Lincoln National Life Insurance Company
1
Voluntary Term Life
Insurance
The Lincoln Term
Life Insurance Plan:
• Provides a cash benefit to
your loved ones in the event
of your death
• Features group rates for
Howard Hanna Real Estate
employees
• Includes LifeKeys® services,
which provide access to
counseling, financial, and
legal support services
• Also includes TravelConnect®
services, which give you and
your family access to
emergency medical
assistance when you’re on a
trip 100+ miles from home
Howard Hanna-Rochester
Benefits At-A-Glance
Employee
Newly hired employee guaranteed
coverage amount $150,000
Maximum coverage amount $500,000 maximum in increments of
$5,000
Minimum coverage amount $5,000
Spouse
Newly hired employee guaranteed
coverage amount $25,000
Maximum coverage amount $250,000
Minimum coverage amount $2,500
Dependent Children
6 months to age 19 (to age 25 if
full-time student) guaranteed
coverage amount
$10,000
Age 14 days to 6 months
guaranteed coverage amount $250
Voluntary Life Insurance Benefits At-A-Glance
LFE-ENRO-BRC001-NE
2
What your benefits cover
Employee Coverage
Guaranteed Life Insurance Coverage Amount
• Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to $150,000
without providing evidence of insurability.
• If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your
own expense.
Maximum Life Insurance Coverage Amount
• You can choose a coverage amount up to $500,000 with evidence of insurability. See the Evidence of Insurability page for
details.
• The maximum coverage amount for employees 70 and older who are electing coverage for the first time is $50,000.
• Your coverage amount will reduce by 35% when you reach age 65; an additional 15% of the original amount when you
reach age 70; and an additional 20% of the original amount when you reach age 75.
Spouse Coverage - You can secure term life insurance for your spouse if you select coverage for yourself.
Guaranteed Life Insurance Coverage Amount
• Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to $25,000
maximum for your spouse without providing evidence of insurability.
• If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your
own expense.
Maximum Life Insurance Coverage Amount
• You can choose a coverage amount up to ($250,000 maximum) for your spouse with evidence of insurability.
• Coverage amounts are reduced by 35% when an employee reaches age 65.
Dependent Children Coverage - You can secure term life insurance for your dependent children when you choose
coverage for yourself.
Guaranteed Life Insurance Coverage Options: $5,000 and $10,000.
Questions? Call 800-423-2765 and mention Group ID: NOTHNAGLE.
This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this
summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made
available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a
difference between this summary and the contract, the contract will govern.
LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. TravelConnect® travel assistance services are provided by On Call
International, Salem NH. On Call International must coordinate and provide all arrangements in order for eligible services to be covered.
ComPsych® and On Call International are not Lincoln Financial Group companies and Lincoln Financial Group does not administer these Services.
Each independent company is solely responsible for its own obligations. Coverage is subject to contract language that contains specific terms,
conditions, and limitations.
Insurance products (policy series GL1101) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit
business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply.
©2019 Lincoln National Corporation LCN-2016746-020518 R 1.0 – Group ID: NOTHNAGLE
Voluntary Life Insurance Benefits At-A-Glance LFE-ENRO-BRC001-NE
3
Additional Plan Benefits
Accelerated Death Benefit Included
Premium Waiver Included
Conversion Included
Portability Included
Benefit Exclusions
Like any insurance, this term life insurance policy does have exclusions. A suicide exclusion may apply. A complete list of
benefit exclusions is included in the policy. State variations apply.
www.LincolnFinancial.com
Group Short-Term Disability InsuranceSpecialty Worksite
SUMMARY OF BENEFITS
Sponsored by: Nothnagle Home Securities Corp. & Nothnagle Realtors
Short-term disability is intended to protect your income for a short duration in case you become ill or injured.
STD Benefit
Weekly Benefit Elimination Period Maximum Duration
Any $100 increment, with a minimum of $100 of coverage
Maximum of $500 per week, not to exceed 60% of salary
Benefits begin on:Accident: 31st dayIllness:31st day
26 weeks
Your benefits may be reduced by benefits received from state disability or worker’s compensation programs. The total of all benefits received from this policy, state disability plans, worker’s compensation programs and your employer’s sick pay plan may not exceed 100% of your income prior to disability.
You will not be required to pay premium during any time of approved total or partial disability.
Additional Benefits
PortabilityRehab Assistance - 5%Survivor Income - 3 WeeksC-Section Benefit - 8 weeksSee your Schedule of Benefits on your Certificate for more information
Enrolling for Coverage
Eligibility: All employees in an eligible class.You are able to take advantage of this coverage now without a health examination. You may not be offered this opportunity again until your annual open enrollment.
Integration of Benefits
Waiver of Premium
©2015 Lincoln National Corporation - NOTHNAGLE-LFG - 8/15-STD - SW - Choice of Increments- Gen -9/8/2015 �
Understanding Your Benefits
Total Disability Due to an injury or illness, you are unable to perform each of the main duties of your regular occupation.
Partial Disability Due to an injury or illness, you are unable to perform one or more of the main duties of your regular occupation on a full-time basis. Partial Disability benefits may be payable if you are earning at least 20% of the income you earned prior to becoming disabled, but not more than 99%. Partial disability benefits allow you to work and earn income from your employer as well as continue to receive benefits, which may enable you to receive 100% of your income during your time of disability.
Continuation of Disability
If you return to work full-time but become disabled from the same disability within 2 weeks of returning to work, you will begin receiving benefits again immediately.
Pre-Existing Condition Any sickness or injury for which you have received medical treatment, consultation, care, or services (including diagnostic measures or the taking of prescribed medications) during the specified months prior to your coverage effective date. A disability arising from any such sickness or injury will be covered only if it begins after you have performed your regular occupation on a full-time basis for the specified months following the coverage effective date.
Benefit Exclusions You will not receive benefits in the following circumstances: x Your disability is the result of a self-inflicted injury. x You are not under the regular care of a doctor when requesting disability benefits. x Your disability is the result of war, declared or undeclared, or any act of war. x Your disability is covered under a worker’s compensation plan and/or is due to a job-
related sickness or injury.
Benefit Reductions Your benefits may be reduced if you are receiving benefits from any of the following sources: x Any governmental retirement system earned as a result of working for the current
policyholder; x Any disability or retirement benefit received under a retirement plan; x Any Social Security, or similar plan or act, benefits; x Earnings the insured earns or receives from any form of employment; x You are receiving sick leave pay from your employer. x Disability income benefits received under state disability benefit laws.
Rehabilitation Assistance Benefit
Employees who participate in an approved rehabilitation program are eligible to receive an additional percent of benefit. Additionally, approved program costs may be reimbursed.
Survivor Income A benefit may be paid to your survivor for additional months if you should die while you were eligible to receive benefits under this policy.
Coverage Termination This coverage will terminate when you terminate employment with this policyholder, or at your retirement.
For assistance or additional information Contact Lincoln Financial Group at
(800) 423-2765; reference ID: NOTHNAGLE www.LincolnFinancial.com
NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.
Insurance products are issued by Lincoln Life & Annuity Company of New York, a Lincoln Financial Group® company. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Limitations and exclusions apply. For use in New York only. ��
Contact Insurance Department for more information:P: (888) 564-0300 | F: (856) 396-3193 | [email protected]
Group Long-Term Disability Insurance Voluntary
}
SUMMARY OF BENEFITS
Sponsored by: Nothnagle Home Securities Corp. & Nothnagle Realtors
Long-term disability is intended to protect your income for a long duration after you have depleted short-term disability or any sick leave your company may offer.
LTD Benefit
Monthly Benefit Maximum Benefit Duration
Own Occupation Period
Elimination Period
Employee Paid Plan
$100 increments up to 60% of monthly salary
Minimum: $500 per monthMaximum: $5,000 per month
2 Years / To Age 70
24 Months 180 Days
Pre-Existing Condition
You may not be eligible for benefits if you have received treatment for a condition within 6 months prior to your effective date under this policy until you have been covered under the policy for 12 months, or you remain treatment free for a period of 12 consecutive months.
Waiver of Premium You will not be required to pay premium during any time of approved total or partial disability.
Benefit Limitations Mental Illness: 24 MonthsSubstance Abuse: No LimitSpecified Illness: No Limit
Enrolling for Coverage
Eligibility: All employees in an eligible class.You are able to take advantage of this coverage now without a health examination. You may not be offered this opportunity again, or may be responsible for the cost of required examinations.
Monthly Premium Calculation**
List your monthly earnings(*Maximum covered payroll is
$8,333 Monthly) $___________
EXAMPLEAge 35
$2,643
Multiply by 60.00% $___________ $1,586Based on the amount shown on
above, determine the coverage you want, not to exceed the number
above
(Round down to the next
lower $100increment)
($1,586 roundsdown to $1,500)
Write the total amount of coverage you have elected, not to exceed the
limit above $__________ $1,500
Multiply by your premium factor ________ 0.00440
Your Estimated Monthly Premium** $___________ $6.60**This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency.
Attained PremiumAge Factor
________________________ 0 - 24 0.00270
25 - 29 0.0027030 - 34 0.0035035 - 39 0.0044040 - 44 0.0054045 - 49 0.0098050 - 54 0.0144055 - 59 0.0252060 - 64 0.0372065 - 69 0.0390070 - 74 0.0233075 - 99 0.02510
©2015 Lincoln National Corporation - NOTHNAGLE-LFG - 8/15-LTD - Voluntary Choice of Increments- Gen -9/8/2015 �
Understanding Your Benefits
Elimination Period
The number of days you must be disabled prior to collecting disability benefits.
Own Occupation The occupation, trade, or profession you were employed in prior to your disability as defined by the US DOL Dictionary of Occupational Titles.
Total Disability Due to an injury or illness, you are unable to perform each of the main duties of your own occupation on a full-time basis. Your “own” occupation is covered for a specific period of time. Following this, the definition of total disability becomes the inability to perform any occupation for which you are reasonably suited based on your experience, education, or training. See Certificate of Coverage for details.
Partial Disability Due to an injury or illness, you are unable to perform one or more of the main duties of your regular occupation on a full-time basis. Partial Disability benefits may be payable if you are earning at least 20% of the income you earned prior to becoming disabled, but not more than 99%. Partial disability benefits allow you to work and earn income from your employer and continue to receive benefits, which may enable you to receive 100% of your income during your time of disability. See Certificate of Coverage for details.�
Continuation of Disability
If you return to work full-time but become disabled from the same disability within 6 months of returning to work, you will begin receiving benefits again immediately with no new Elimination Period.
Benefit Duration Reduction
Your benefit duration may be reduced if you become disabled after age 65.
Pre-Existing Condition
Any sickness or injury for which you received medical treatment, consultation, care, or services (including diagnostic measures or the taking of prescribed medications) during the specified months prior to your coverage effective date. A disability arising from any such sickness or injury will be covered only if it begins after you have performed your regular occupation on a full-time basis for the specified months following the coverage effective date, unless no treatment was received for the specified consecutive months after the coverage effective date.
Benefit Exclusions
You will not receive benefits in the following circumstances: x Your disability is the result of a self-inflicted injury. x You are not under the regular care of a doctor when requesting disability benefits. x You were involved in a felony commission, act of war, or participation in a riot. x You were residing outside of the United States or Canada for more than 12 consecutive months
for purposes other than employment with your Employer. Benefit Reductions
Your benefits may be reduced if you are receiving benefits from any of the following sources: x Any compulsory benefit act or law (such as state disability plans); x Any governmental retirement system earned as a result of working for the current policyholder; x Any disability or retirement benefit received under a retirement plan; x Any Social Security, or similar plan or act, benefits; x Earnings from any form of employment; x Workers compensation; x Salary continuance or employer contributions to an employer sponsored retirement plan.
Coverage Termination
Coverage will terminate when you terminate employment with this policyholder, or at your retirement.
Additional Benefits
Family Care Expense Benefit, Survivor Income Benefit, EmployeeConnect - Employee Assistance Program and Waiver of Premium
See your Schedule of Benefits on your Certificate for more information
For assistance or additional information Contact Lincoln Financial Group at
(800) 423-2765; reference ID: NOTHNAGLE www.LincolnFinancial.com
NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.
Insurance products are issued by Lincoln Life & Annuity Company of New York, a Lincoln Financial Group® company. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Limitations and exclusions apply. For use in New York only.
Contact Insurance Department for more information:P: (888) 564-0300 | F: (856) 396-3193 | [email protected]
Howard Hanna- Rochester Group Insurance Rates
Agent Agent $7.89Two or More Agent/Spouse $15.77
Agent & Child $15.77Agent Agent & Children $23.66Two or More Family $23.66
Age Rate0-29 $23.92
30-34 $22.3635-39 $21.3240-44 $21.3245-49 $23.4050-54 $26.5255-59 $32.2460-64 $38.4865-69 $43.1670-74 $47.3275-99 $47.32
Age Rate0-29 $2.81
30-34 $3.6435-39 $4.5840-44 $5.6245-49 $10.1950-54 $14.9855-59 $26.2160-64 $38.6965-69 $40.5670-74 $24.2375-99 $26.10
Long-Term DisabilityMonthly Rates Per**
$1,000 Monthly Benefit Amount
Lincoln Financial Group
$500 Weekly Benefit Amount
Effective 5/1/2019 to 4/30/2022
Lincoln Financial GroupShort-Term Disability
Monthly Rates Per**
$30.61$87.28
Comprehensive Plan Monthly Rates*$44.52$138.53
Effective 1/1/2020 to 12/31/2020
MetLifeDental Coverage Davis Vision
Basic Plan Monthly Rate* Monthly Rates*
*These rates include a 6% administrative fee.
**These rates include a 4% administrative fee. These rates are for illustrative purposes and are subject to change without notice. For more specific information refer to the highlight sheets.
Revised 7/14/2020
Age0-29
30-3435-3940-4445-4950-5455-59
Dependent Child Life$5,000
Age60-641
65-692
you may be denied.Spousal rates are based on the agent’s date of birth1Max benefit of $250,000 2Max benefit of $162,500
Monthly Rates**$6,500 Guarantee Issue Amount
$15.22 Amounts over $10,000
� Require Evidence of Insurability Paperwork� Are subject to underwriting requirements and
Monthly Rates**$10,000 Guarantee Issue Amount
Rates$11.96
� Require Evidence of Insurability Paperwork
� Are subject to underwriting requirements and you maybe denied.
Spousal rates are based on the agent’s date of birth.
Lincoln Financial GroupLife Insurance Over Age 60
$26.52 $45.24 $78.00
$117.00
$1.04
Amounts over $150,000
$150,000 Benefit AmountRate
$10.92 $14.04$18.72
Lincoln Financial GroupLife Insurance
Monthly Rates**
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
ENROLL 18 CA Continue on Next Page. . . 1
The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE 68103-2616 Phone: 800-423-2765 Fax: 877-573-6177
Here is your Enrollment Form.
Group ID: NOTHNAGLE
1. Your Personal Information
Group/Employer/Participating Organization Name
Howard Hanna-Rochester
County Zip State
Your First Name Middle Name/MI Last Name Social Security No.
- -
Employee ID No. Date of Birth
/ /
Street Address (Include Apt. or Suite No.) City State Zip
Home Phone
( ) -
Cell Phone
( ) -
Work Phone
( ) -
Email Address
Gender: Male Female Marital Status: Married Single
2. Personal Information on Dependents — Complete if you are enrolling dependents.
Spouse Domestic Partner
First Name Middle Name/MI Last Name Social Security No.
- -
Date of Birth
/ /
Provide contact information if different than Your information above.
Home Phone
( ) -
Cell Phone
( ) -
Work Phone
( ) -
Email Address
Dependent Children – List all children you are enrolling (attach a separate sheet, if needed). First Name Middle Name/MI Last Name SSN (Optional)
- -Gender
Male Female DOB / /
Full-time Student Yes No
- - Male Female / / Yes No - - Male Female / / Yes No
Employer Completes this Section. Billing Division or Location:
Sort Group/Code: Payroll Cycle:
Policy #(s):
Average Hours Worked Per Week: Full-time Part-time Occupation:
Earnings: Hourly Weekly Monthly Yearly $ Date of Employment: / /
Actively at Work? Yes No Date of Rehire: / /
Follow these steps to complete the form. Print clearly in ink. Step 1: Fill in or confirm your personal information. Step 2: Fill in dependent information, if any. Step 3: Select your benefits. Step 4: Assign beneficiaries. Step 5: Confirm enrollment. Step 6: Sign, date & return the form.
ENROLL 18 CA Continue on Next Page. . . 2
3. Benefit Selection — Continued. Choose your benefits.
Voluntary/Optional Group Insurance Mark the box or boxes for each type of group insurance you are applying for. All insurance amounts are subject to the limitations and exclusions as stated in the policy and certificate. (Spouse includes your Domestic Partner.)
Employer Completes this section. Type of Insurance
Amount of Insurance
Total Premium (Weekly)
Class Effective Date
/ / Voluntary Life Only Yes No* $ $
/ /
Voluntary Dependent (Spouse Only)
Life Only Yes No* You must be enrolled for Life insurance in order to add spouse and/or child insurance. $ $
/ /
Voluntary Dependent (Child Only)
Life Only Yes No* You must be enrolled for Life insurance in order to add spouse and/or child insurance. $ $
/ / Voluntary Short Term Disability (STD) Yes No* (STD)
Weekly Benefit Amount: $ $
/ / Voluntary Long Term Disability (LTD) Yes No* (LTD)
Monthly Benefit Amount: $ $
*By selecting “No,” application for insurance at a later date may require further medical information and/or a physical exam, whichwill be at my own expense.
--Actual deductions may vary slightly from above illustrations due to rounding--
ENROLL 18 CA Continue on Next Page. . . 3
4. Select Your Beneficiaries — Choose who receives your insurance benefits.
Primary Beneficiary(ies) The Primary Beneficiary is the person(s) you identify to receive insurance benefits upon your death.
If more than three Primary Beneficiaries, please attach a separate sheet of paper. If multiple Primary Beneficiaries, total percentage of all combined must equal 100%.
First Name Middle Initial Last Name
Street Address City State Zip
Social Security Number
- -
Date of Birth
/ /
Relationship to You Percentage
%
Phone Number
( ) -
First Name Middle Initial Last Name
Street Address City State Zip
Social Security Number
- -
Date of Birth
/ /
Relationship to You Percentage
%
Phone Number
( ) -
First Name Middle Initial Last Name
Street Address City State Zip
Social Security Number
- -
Date of Birth
/ /
Relationship to You Percentage
%
Phone Number
( ) -
Contingent Beneficiary(ies) and Other Beneficiary Designations A Contingent Beneficiary will receive benefits only if the Primary Beneficiary(ies) does not survive you. Please attach a separate
sheet to identify a Contingent Beneficiary. If multiple Contingent Beneficiaries, total percentage of all combined must equal 100%. To name a Beneficiary(ies) by product, attach a separate sheet identifying product and beneficiary.
ENROLL 18 CA 4
5. Confirm Enrollment This group insurance has been offered to me and after careful consideration of the benefits, I have decided to:
ENROLL FOR INSURANCE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company, or its insurance partners. If contributions are required, I authorize my Employer to deduct premium from my pay.
NOT ENROLL myself in the group insurance offered. I understand if I enroll for insurance at a later date, and if a physical examination or further medical information is required, it will be at my own expense.
NOT ENROLL my dependents in the group insurance offered. I understand if I enroll my dependents for insurance at a later date, and if a physical examination or further medical information is required, it will be at my own expense.
Fraud Warning/State Disclosure(s) A PERSON MAY BE COMMITTING INSURANCE FRAUD IF HE OR SHE SUBMITS AN APPLICATION CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH THE INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY. THE FALSITY OF ANY STATEMENT IN THIS APPLICATION SHALL NOT BAR THE RIGHT TO RECOVERY UNDER THE POLICY UNLESS SUCH FALSE STATEMENT WAS MADE WITH ACTUAL INTENT TO DECEIVE OR UNLESS IT MATERIALLY AFFECTED EITHER THE ACCEPTANCE OF THE RISK OR THE HAZARD ASSUMED BY THE INSURER.
CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE.
6. Sign and Return I understand the group insurance requested will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, or its insurance partners. A delayed effective date will apply if you are not Actively at Work/an Active Member. A delayed effective date may apply to your dependent, if he or she is confined in a hospital or health care facility or is in a period of limited activity on the date insurance would otherwise take effect.
I understand that the vision insurance I have elected provides reimbursement for certain vision costs which are more fully described in the current Certificate of Coverage. I understand there may be instances where treatment decisions made by my provider or me for vision care expenses that I have incurred may not be covered by my vision care insurance benefit plan.
I understand the information provided is for enrollment in group insurance as offered by my Employer and will not be used for underwriting purposes.
The information provided is complete, true, and accurate to the best of my knowledge.
Your Full Name (Print):
Your Signature: X Date / /
Complete and return this form. (Be sure to sign and date the form to start your insurance.)
Questions? Call 800-423-2765
SIGNATURE of account owner*
*Note: Signature should be that of the owner of the checking account whose name appears on the check used for deductions.
SIGNATURE of insured
Revised 4/04/2016
DATE
DATE
Automatic Deduction and Notification AgreementPLEASE READ CAREFULLY. BY SIGNING BELOW, YOU AGREE TO HAVING READ AND UNDERSTOOD THE FOLLOWING:
I hereby authorize Realty Benefit Services, an affiliate of Dergalis Associates, to access my account for the
dental, vision, life, and / or disability insurance premiums. I understand that these deductions will be made periodically and I realize that changes in premiums may result in higher or lower deductions. I further understand that I shall incur additional charges in the event this debit is returned for any reason. In the event that Realty Benefits Servicesthe month, I will be charged $25.00. I understand there is no monthly paper billing from Realty Benefit Services, an affiliate of Dergalis Associates and I cannot pay by check.
SOCIAL SECURITY # EMAIL
HOME PHONE
HOME ADDRESSCITY STATE ZIP
CELL PHONE
REALTY COMPANY OFFICE LOCATION
Notifications
notify Dergalis Associates within 30 days of my termination, I realize I may continue to get billed for
NO REFUNDS WILL BE PROVIDED FOR MY FAILURE TO NOTIFY DERGALIS ASSOCIATES OF TERMINATION OR SEPARATION FROM MY REAL ESTATE COMPANY. I understand that any changes to or termination of my coverage will also affect the coverage I have elected for my dependents.By signing, I acknowledge that I have read and accept the terms of the above notification agreement.
NAME OF INSURED
WERE YOU HELPED BY A DERGALIS REPRESENTATIVE? (please check) YES NO
IF YES, WHO:
Page 2 of 3
SIGNATURE REQUIRED
SIGNATURE REQUIRED
I agree to provide signed written notice at least two weeks in advance in the event I wish to cancel, change or amend my current policies. I further agree to indemnify and hold harmless Realty Benefit Services, an affiliate of Dergalis Associates, for charges assessed on my account from my lending institution due to debits for services rendered. I agree to notify Realty Benefit Services, an affiliate of Dergalis Associates, in writing of any changes to my bank account. This notice will be at least two weeks in advance of any scheduled payment debits. (You can email your notice to Dergalis Associates at [email protected].)
I understand that these services are being provided solely through arrangements with Realty Benefit Services, an affiliate of Dergalis Associatesthat I must notify Dergalis Associates in writing if I no longer work as a licensed Realtor or become a
Attach Voided Check
Attach Your Business Card
Page 4 of 4
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L 8� � � } � þ � ~ � � H I þ � � þ � � � � � � � � � � � ÿ H � � � � � � � � � ÿ � � � � � � � � � � � � � þ ß � � � � � � � � ÿ à � � � � � � ÿ � � � � ÿ �ÿ � � � þ � < � þ < � � ÿ � � � � Ï � � � � ÿ � � � � � � � � � ÿ � � þ � � � � � þ ß � � � � � � � � � � � ÿ à � � � � � � ÿ � � � � ÿ �ÿ � � � þ � < � þ < � � ÿ � � � � Ï � � � � ÿ � � � � � � � � J K : ? L 8 K : ? L 8 � � } � þ � ~ � � H þ � � � � � � � � � � � � þ � < � � ÿ þ � � � ÿ � � � � � # þ � < � � ÿ � � � ÿ � � ÿ � � � � þ � � þ � � � � � ÿ� � � � ÿ � � � � þ � � ß � þ < � � � � � � � ÿ � � � � ÿ � à � ÿ � � � � � � þ ÿ � � � þ � � þ � � � � � � < � � � ÿ þ � ÿ � � � � � I þ � � þ �� � � � � � � � � � � � � � J K : ? L 8 K : ? L 8Í � � � � � � � � � � � � � � � þ � < � � ÿ þ � � � ÿ � � � � ÿ ÿ � � � � � � � � � ÿ � � � � ÿ u � � þ � � � ÿ � ÿ � � � � � � � � � � � � � � þ þ � � J K : ? L 8 K : ? L 8� � � � � � � � � � � � � � þ � < � � ÿ þ � � � ÿ � � � � ÿ ÿ � � � � � � � # þ � < � � � � � � þ � � þ � � ß � à � ÿ � � ÿ þ � � � � � �� � � � þ þ � � J K : ? L 8 K : ? L 8� � q r B C r A B C : 6 D ? B | 9 : D t ? G � � � � � � � � � � � � � � þ � < � � ÿ þ � � � ÿ � � � � � � � � þ � < � � � � � � ÿ � ÿ � � � � � � � ÿ �� � � þ � � ÿ � � ÿ � � � � � � � # H � � # H � ÿ � � þ � � J K : ? L 8 K : ? L 8� � � � � � � � ÿ � � ÿ þ � þ � H z � � � � � � � þ � Î ÿ � � ÿ þ � þ � H � ÿ � � < � � � ÿ � � þ u � � � þ � � � þ � � � � � J K : ? L 8 K : ? L 8 � � � � ÿ � � � � ÿ � � � � < � � � � � � � þ < � � � � � � H � ÿ � þ � � < � H � ÿ � � � þ � � � � � � � � # � � � J K : ? L 8 K : ? L 8� � q r B C r A B C : 6 D ? B F � 5 8 A B C ? 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