Enrollment

IBEW LU # (not your personal number)*

Full Name*

Email*

Phone*

Gender*

Male
Female

Date of Birth*

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Age

Billing Street Address*

Billing City, State, Zip*

Date of Hire*

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Date of Hire (Import)

Occupation*

Hours Worked Per Week*

Hourly Wage*

Total Amount of Benefit Applied For (per month)

Monthly Premium

See Premium Table

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 and 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

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.

Method of Payment*

Automatic monthly withdraw from bank account
Debit/Credit Card Recurring Payment

15621 W. 87th St. Parkway #223
Lenexa, KS 66219
913 - 498 - 9090 xt 7229

Electrical Worker’s
Long Term Disability Income Protection Trust

Schedule your payment to be automatically deducted from your checking or savings account.
Just complete and sign this form to get started!

Recurring Payments Will Make Your Life Easier

It's convenient (saving you time and postage)
Your payment is always on time (even if you're out of town), eliminating late charges

Here's How Recurring Payments Works

You authorize regularly scheduled charges to your checking account. You will be charged the amount indicated each billing period. A charge will appear on your bank statement as an "ACH Debit." You agree that no prior -notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

By entering your full name, you authorize Sagebrush Insurance Services, Inc. to charge my bank account indicated below on the 1st of each month for payment of my insurance premium.

Bank Account Type*

Checking
Savings

Name on Bank Account*

Bank Name*

Bank Routing #*

Bank Account Number*

Bank City/State*

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Sagebrush Insurance Services, Inc., in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Sagebrush Insurance Services, Inc. may at its discretion attempt to process the charge again within 30 days, and agree to an additional $10.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

15218 W. 83rd Terrace
Lenexa, KS 66219
913 - 498 - 9090 xt 7229

Electrical Worker’s
Long Term Disability Income Protection Trust

Schedule your payment to be automatically deducted from your debit or credit card.
Just complete and sign this form to get started!

Recurring Payments Will Make Your Life Easier

It's convenient (saving you time and postage)
Your payment is always on time (even if you're out of town), eliminating late charges

Full Name on Card*

Type of Card*

Debit Card
Credit Card

Card Network*

Visa
Mastercard
Discover
American Express

Card Number*

Card Verification (CVV) Number/Security Code*

Expiration Date (mm/yy)*

Total amount to be charged will be the premium + transaction fees. Transactions will be processed the 1st day of each month for that month’s coverage.

I acknowledge the charges described hereon and assume full responsibility for said premiums and any fess associated with this transaction and agree to honor and abide by the terms of payment. I acknowledge and accept that this authorization will remain in effect until I cancel it in writing, and I agree to notify Sagebrush Insurance Services, Inc., in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. In the case of a Transaction being rejected I understand that Sagebrush Insurance Services, Inc. may at its discretion attempt to process the charge again within 30 days and agree to an additional $10.00 charge for each attempt returned, which will be initiated as a separate transaction from the authorized recurring payment. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

Do you wish to sign right now?*

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Signature

Name

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