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Reliance Standard Life Insurance Company - Enrollment
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I understand and agree that:
• The information provided on this Enrollment and Statement of Health form is true and correct to the best of my knowledge.
• The insurance requested will become effective in accordance with the individual effective date information in the Policy; any amount subject to evidence of insurability will not become effective until approved by Reliance Standard and Reliance Standard has the right to refuse my request. Coverage is subject to a minimum participation requirement at the employer level and if the minimum is not met, coverage may not be issued even though an enrollment form has been completed. An effective date is subject to eligibility requirements, satisfaction of service waiting period (if applicable) and payment of first premium when due. An effective date may be deferred for an employee not actively at work and enrolled dependents confined to a hospital or at home.
• Benefits are subject to terms and conditions of the Policy.
• For age-banded rate plans, premiums increase as an employee moves from one age band to the next.
• If payroll deduction of premiums begins prior to Reliance Standard’s processing of the enrollment form, it does not mean coverage is in effect; premiums paid for coverage not issued will be returned.
• I am actively employed.
I further understand agree that if I am applying after the expiration of my initial eligibility period, all medical tests and costs for attending physician reports may be without expense to Reliance Standard Life Insurance Company and I may be responsible for paying the expenses, if any.
The long-term disability benefits have been explained and I understand the coverage I am applying for as well as the pre-existing conditions clause.
PRE-EXISTING CONDITIONS: You will be considered to have a Pre-existing Condition and will be subject to the Pre-existing Conditions Limitation if: (1) the Total Disability begins in the first twelve (12) consecutive months after your effective date; and (2) you have received medical Treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines for the Sickness or Injury, whether specifically diagnosed or not, causing such Total Disability, during the three (3) months immediately prior to your effective date of insurance.
I acknowledge receipt of “Important Information Regarding Applications for Insurance”.
Please Note: During an approved enrollment, guaranteed issue amounts of insurance will not require a Statement of Health form provided the Enrollment form is complete, signed and received by your employer during your enrollment period and: a) you are not a late applicant with respect to insurance for yourself; or b) during your present service with your employer or an affiliate, you have not, with respect to insurance with Reliance Standard had an application withdrawn; been previously declined; had coverage postponed; or voluntarily terminated within the past 5 years; or c) the enrollment period is not one with specific guaranteed issue/health acceptability rules.
LRS-9457-0111-KS
Reliance Standard
Life Insurance Company
A Member of Tokio Marine Group
Home Office: Schaumburg, Illinois
Administrative Office: Philadelphia, Pennsylvania
Signature
ELIMINATION PERIOD
180 consecutive days of total disability
MAXIMUM BENEFIT DURATION
Benefits will not extend beyond the longer of: Social Security, Normal Retirement Age or Duration of Benefits (See Certificate)
LIMITATIONS
Mental/Nervous Illness Limitation - 24 Months out-patient Offsets (such as, but not limited to Social Security, Workers Compensation, State Disability Plan) Pre-existing Condition Limitation - 3/12 Substance Abuse Limitation - 24 Months Please note-pre-existing limitations also apply to benefit increases
EXCLUSIONS
Benefits will not be payable for any disability caused by: an intentionally self-inflicted injury, and act of war (declared or undeclared); commission of a felony; injury or sickness occurring while confined in any penal or correctional institution. For a comprehensive list of exclusions, limitations, and any applicable benefit offsets, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits. This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS‐6564, et al.
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