keep this notice for your records. - Archdiocese of Cincinnati

R:\CLNTDOCS\03\GBS\20414.doc 

Archdiocesan Health Care Plan 

Universal Enrollment Form Location No.: 

Anthem – Medical Plan 

PLAN NAME/GROUP NUMBER: 

ARCHDIOCESE OF CINCINNATI – 1050900 

SOCIAL SECURITY NUMBER: 

PHONE NO.: 

NEW ENROLLMENT 

OPEN ENROLLMENT 

WAIVER CHANGE TRANSFER 

ACTIVE RETIRED UNDER OR OVER 65 SEMINARIAN 

MEMBER NAME FIRST M.I. LAST LAY PRIEST BROTHER/SISTER 

SURVIVING SPOUSE/DEPENDENT TEACHER 

MEMBER ADDRESS STREET CITY STATE ZIP SALARY MONTH OR ANNUAL DATE OF HIRE 

EMPLOYEE’S HOME PHONE EMPLOYEE’S WORK PHONE COUNTY IN WHICH YOU RESIDE 

LOCATION NAME: MARITAL STATUS ARE YOU COVERED UNDER ANOTHER POLICY? YES NO 

MARRIED SINGLE DIVORCED 

IS SPOUSE EMPLOYED? YES NO IS SPOUSE ELIGIBLE FOR OTHER GROUP COVERAGE? YES NO IF SO, NAME OF CARRIER: 

SPOUSE’S EMPLOYER NAME SPOUSE’S EMPLOYER’S ADDRESS CITY STATE ZIP PHONE 

HOW MANY HOURS PER WEEK WORKED HOW IS YOUR INCOME REPORTED? (W2, 1099, OTHER) 

EMPLOYEE SOCIAL SECURITY NUMBER DATE OF BIRTH GENDER EFFECTIVE DATE 

SPOUSE 

CHILD 

CHILD 

CHILD 

Coverage(s) Elected 

Other Insurance Information 

If you or any of your family members have other group coverage, CHECK all that apply. 

Health: Policy # Dental: Policy # 

Prescription Drug Coverage: Policy # 

Vision: Policy # Hearing: Policy # 

If you answered yes to the above, is the insurance: Single Coverage or Family Coverage 

EMPLOYED BY Insured’s Name Date of Birth 

Insurance Company Name Street Address 

City State Zip Phone 

I APPLY FOR COVERAGE AS INDICATED ABOVE, for which I am or may become eligible under the agreement with Anthem BCBS (providing hospital, medical, and health 

maintenance coverage), (the Company). I have read the above statements and represent they are true and complete to the best of my knowledge. I authorize my employer/group to 

deduct from my pay and remit any required contribution for the cost of said coverage. This authorization is to remain in effect until the Company is notified by me in writing to the contrary. 

I understand the benefits listed in the Certificate(s) will be available subject to the Terms and Conditions thereof effective as listed in the Certificate(s) of Coverage. 

Employee Signature Date Signed 

DECLINING COVERAGE 

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your 

dependents in this plan, provided that you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, 

adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 31 days after the marriage, birth, adoption, or 

placement for adoption. 

I do not wish to enroll at this time and understand that the opportunity to enroll at any future time will be subject to such arrangements as may be made with the Company. 

Not enrolling for: Myself My spouse My spouse and dependents My dependents 

Myself, my spouse and my dependents To waive pretax deduction 

Employee Signature Date Signed 

Page 1 of 10


TYPE OF COVERAGE EMPLOYEE SPOUSE CHILD EFFECTIVE DATE 

Yes No Yes No Yes No 

ANTHEM BLUE ACCESS (PPO) 

LIFE 

LONG-TERM DISABILITY 

VOLUNTARY LIFE 

VOLUNTARY DENTAL 

� CHANGE 

LOCATION TRANSFER: ADD DEPENDENT(S) 

FROM: TO: CHANGE BENEFICIARY DATE OF ADDITION: 

FULL TIME STUDENT ADOPTION (Attach Legal Document) 

PART TIME TO FULL TIME LEGAL GUARDIAN (Attach Legal Document) 

NAME CHANGE: RETIREE 65 AND OVER, SUPPLEMENTAL MARRIAGE 

FROM: TO: SPOUSE/DEPENDENT UNDER OWN SSN NEWBORN 

OTHER (Specify:) 

ADDRESS CHANGE (list above) 

I and the Archdiocese of Cincinnati agree that my pay will be reduced by the amount of my required contribution for the benefit options I have elected under the Cafeteria Plan, and 

continuing for each succeeding pay period until this agreement is amended or terminated. The amount of my required contribution for the medical and/or dental benefit options selected 

have been separately communicated to me by Archdiocese of Cincinnati. 


SIGNATURE DATE 

The Medical Benefits have been explained to me thoroughly. Unless otherwise indicated above, I DO NOT wish to enroll for medical coverage and understand that I will not be entitled to 

any benefits provided by the Plan. If I wish to enroll at a later date, I may be required to submit satisfactory evidence of good health at that time. 


EMPLOYER VERIFICATION: I have reviewed the application and believe to the best of my knowledge the information supplied by the insured is accurate and the insured is eligible for 

coverage under the plan. 





– Life & LTD Beneficiary Designation/Change 

This designation will apply to the following Standard Insurance Company coverage(s) if available to you through your Employer: Life Insurance, Life with Accidental 

Death & Dismemberment (AD&D). 

Designations made below, or on a separate sheet of paper, are not valid unless signed, dated, and delivered to the Employer during your lifetime. 

Sign and date the completed form and return it to your Human Resources Department. 

MEMBER/EMPLOYEE INFORMATION 

Group name Group No. 

BENEFICIARY INFORMATION 

� Your designation revokes all prior designations. 

� Benefits are payable to a contingent Beneficiary only if you are not survived by one or more primary Beneficiaries. 

� If you name two or more Beneficiaries in a class (primary or contingent), two or more surviving Beneficiaries will share equally, unless you provide for unequal 

shares. 

� If a minor (a person not of legal age) or your estate is the Beneficiary, it may be necessary to have a guardian or a legal representative appointed by the court 

before any death benefit can be paid. If the Beneficiary is a trust or trustee, the written trust must be identified in the Beneficiary designation. For example, 

“Dorothy Q. Smith, Trustee under the trust agreement dated .” 

� A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or change a Beneficiary designation. If you have 

questions, consult your legal advisor. 

� Dependents Insurance and Supplemental Life insurance on your Spouse, if any, is payable to you, if living, or as provided under your Employer’s coverage 

under the Group Policy. 

� If you complete the “% of Benefit” box(es), the amounts should add up to 100% for each class (primary or contingent). For example, “Primary – John Q. Doe, 

60%; Jane Q. Doe, 40%.” 

Primary – Full Name Address Soc. Sec. No. Relationship % of Benefit 

Contingent – Full Name Address Soc. Sec. No. Relationship % of Benefit 

Signature of Member/Employee Date 




Dental Care Plus, Inc. 

100 Crowne Point Place – Cincinnati, OH 45241 

Phone (513) 554-1100 – 1-800-367-9466 

Indemnity Plan 

ALL SECTIONS MUST BE COMPLETED FOR APPLICATION TO BE PROCESSED 

SOCIAL SECURITY NUMBER 

EMPLOYEE LAST NAME FIRST NAME MI 

HOME ADDRESS APT# 

CITY STATE ZIP CODE 

GROUP NUMBER 

MARITAL STATUS: EMPLOYMENT DATE 

Single (01) Married (02) 

EMPLOYEE’S HOME PHONE 

SEX 

COUNTY IN WHICH YOU RESIDE 

EMPLOYER AND LOCATION 

EMPLOYEE’S WORK PHONE 

EFFECTIVE DATE 

DATE OF BIRTH 

APPLICATION FOR DENTAL COVERAGE (CHECK THOSE THAT APPLY) EMPLOYEE SPOUSE CHILD(REN) 

COMPLETE THE FOLLOWING INFORMATION FOR EACH DEPENDENT TO BE COVERED BY THE PLAN 

NAME – IF LAST NAME DIFFERENT FROM ABOVE INDICATE LAST NAME RELATIONSHIP SEX BIRTH DATE 

01 SPOUSE 

02 

03 

04 

05 

06 

WILL YOU OR ANY DEPENDENT HAVE OTHER DENTAL INSURANCE COVERAGE? 

IF YES, PLEASE LIST THE NAME OF THE OTHER INSURANCE COMPANY AND PHONE NUMBER: 

REFUSAL/WAIVER – COMPLETE ONLY IF YOU ARE DECLINING COVERAGE FOR YOURSELF OR ANY DEPENDENT 

I DECLINE COVERAGE FOR: 

REASON FOR REFUSAL: 

MYSELF MY SPOUSE MY CHILDREN 

On behalf of myself and any dependants listed above, I hereby apply for coverage under the Master Group Policy issued to my employer by Dental Care Plus, Inc. I 

understand that the benefits for which I (we) will be eligible are in accordance with those described in the Master Group Policy and any changes provided for therein. 

I understand that certain services may require copayment or deductible, payable by me (or my dependents) directly to the provider of such services. I authorize my 

employer to deduct the necessary contributions, if any, from my wages or salary, with the understanding that he acts as my agent in all dealings with the plan, and 

that all acts performed by him and all notices given to him in such dealings are binding upon me, as not prohibited by statute or regulation. 

I hereby waive the dentist-patient privilege and authorize any dentist or other provider of dental services to give Dental Care Plus, Inc., its agents and representatives 

any information concerning the claims for reimbursement for covered services of any person included under such coverage, including the undersigned, the 

undersigned’s spouse and the undersigned’s dependents. 

To the best of my knowledge, the above information is complete, true, and correct. In the absence of fraud, however, all statements made by applicants or by an 

insured person shall be deemed representations and not warranties. 

EMPLOYEE SIGNATURE DATE 

CITY/STATE 

Fraud Notice – Ohio Residents Only: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits 

an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. 

Fraud Notice – Kentucky Residents Only: Any person who knowingly and with intent to defraud any insurance company or other person files an 

application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact 

material thereto commits a fraudulent act, which is a crime. 




Dental Care Plus, Inc. 

100 Crowne Point Place – Cincinnati, OH 45241 

Phone (513) 554-1100 – 1-800-367-9466 

DHMO Plan 

ALL SECTIONS MUST BE COMPLETED FOR APPLICATION TO BE PROCESSED 

SOCIAL SECURITY NUMBER 

EMPLOYEE LAST NAME: FIRST NAME MI 

HOME ADDRESS APT# 

GROUP NUMBER. 

SEX 

MARITAL STATUS EMPLOYMENT DATE 

Single (01) Married (02) 

EMPLOYER AND LOCATION 

DATE OF BIRTH 

CITY STATE ZIP CODE 

EFFECTIVE DATE 

APPLICATION FOR DENTAL COVERAGE (CHECK THOSE THAT APPLY) EMPLOYEE SPOUSE CHILD(REN) 

COMPLETE THE FOLLOWING INFORMATION FOR EACH DEPENDENT TO BE COVERED BY THE PLAN 

NAME – IF LAST NAME DIFFERENT FROM ABOVE INDICATE LAST NAME RELATIONSHIP SEX BIRTH DATE 

01 SPOUSE 

02 

03 

04 

05 

06 

WILL YOU OR ANY DEPENDENT HAVE OTHER DENTAL INSURANCE COVERAGE? 

IF YES, PLEASE LIST THE NAME OF THE OTHER INSURANCE COMPANY AND PHONE NUMBER: 

REFUSAL/WAIVER – COMPLETE ONLY IF YOU ARE DECLINING COVERAGE FOR YOURSELF OR ANY DEPENDENT 

I DECLINE COVERAGE FOR: 

REASON FOR REFUSAL: 

MYSELF MY SPOUSE MY CHILDREN 

On behalf of myself and any dependants listed above, I hereby apply for coverage under the Master Group Contract issued to my employer by Dental Care Plus, Inc. 

I understand that the benefits for which I (we) will be eligible are in accordance with those described in the Master Group Contract and any changes provided for 

therein. I understand that certain services may require copayment or deductible, payable by me (or my salary, with the understanding that he acts as my agent in all 

dealings with the plan, and that all acts performed by him and all notices given to him in such dealings are binding upon me, as not prohibited by statute or regulation. 

I hereby waive the dentist-patient privilege and authorize any dentist or other provider of dental services to give Dental Care Plus, Inc., its agents and representatives 

any information concerning the claims for reimbursement for covered services of any person included under such coverage, including the undersigned, the 

undersigned’s spouse and the undersigned’s dependents. 

To the best of my knowledge, the above information is complete, true, and correct. In the absence of fraud, however, all statements made by applicants or by an 

insured person shall be deemed representations and not warranties. 

EMPLOYEE SIGNATURE DATE 

CITY/STATE 

Fraud Notice – Ohio Residents Only: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits 

an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. 

Fraud Notice – Kentucky Residents Only: Any person who knowingly and with intent to defraud any insurance company or other person files an 

application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact 

material thereto commits a fraudulent act, which is a crime. 


EMPLOYER: We do not accept faxed 

forms. Submit completed enrollment 

applications for insurance to: 

Reliance Standard 

P.O. Box 7818 

Philadelphia, PA 19101-7818 



Archdiocese of Cincinnati 

BG 

RSO 

VG GI: 

000001 

Chicago 

$50,000/$10,000/$20,000/Yes 

ENROLLMENT APPLICATION 

Policy Number: VG 175294 

All sections must be completed to ensure accurate processing. PRINT IN BLUE OR BLACK INK. 

EMPLOYEE INFORMATION 

Reason for Completing Form: Initial Eligibility/New Hire Late Applicant Approved Annual Enrollment 

Change Nature of Change(s): 

/ / 

F M 

First Name Middle Initial Last Name Date of Birth Age State of Birth 

Gender 

(Home Address) Street Apt. City State Zip Daytime Phone Number 

/ / 

Social Security Number Date of Hire Job Title or Position Number of Hours Worked Per Week 

Are you actively performing all the duties of your occupation or profession? Yes No 

IF “NO”, explain: 

COVERAGE SELECTION 

Select the insurance plans and benefit levels that meet your needs. Have your Plan Highlights sheets and Premium Table sheets handy for 

reference. Plans may have limitations, exclusions, reduction in benefit provisions and terms under which coverage may be continued in force or 

terminated. Read your Certificate or Policy of Insurance carefully. 

“YES” 

AUTHORIZES 

EMPLOYER TO 

TOTAL AMOUNT OF 

PAYROLL DEDUCT (A)DD OR COVERAGE APPLIED IF (C), I WANT TO 

PLAN 

PREMIUMS (C)HANGE 

FOR 

CHANGE EXISTING BY PREMIUM 

Voluntary Term Life: Employee 

Yes No* $ + $ 

See 

(Evidence of Insurability (EOI) may be 

required – see accompanying EOI form.) 

- $ 

Premium 

Table 

Voluntary Term Life: Spouse 

Yes No* $ + $ 

See 

(Evidence of Insurability (EOI) may be 

required – see accompanying EOI form.) 

- $ 

Premium 

Table 

Voluntary Term Life: Dep Children Yes No* $2,500 $5,000 TO: 

See 

(Coverage subject to election of 

employee or spouse Term Life) 

$7,500 $10,000 $2,500 

$7,500 

$5,000 

$10,000 

Premium 

Table 

* If you check “NO,” please note that if you desire insurance on yourself and/or your spouse (if applicable) at a later date: (1) you may be required to 

furnish, at your own expense, evidence of each person’s insurability; and (2) Reliance Standard will have the right to refuse your request. 

LRS-9381-0906-OH 




BENEFICIARY INFORMATION 

Complete the following: 

Your Beneficiary’s Name* Date of Birth 

First 

Primary 

Middle Initial Last Relationship to You Month/Day/Year Social Security Number 

Contingent 

* IMPORTANT: When naming a female beneficiary, show the name as Jane J. Doe, not Mrs. John H. Doe. 

A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. You are automatically the Beneficiary for 

Dependent Insurance, unless you otherwise specify. To designate more than one Primary or Contingent Beneficiary, attach a completed Reliance 

Standard Designation of Beneficiary form (obtain this form from your Benefits Administrator). Your intentions must be clearly set forth. 

ADDITIONAL INFORMATION 

IF YOU SELECTED TERM LIFE INSURANCE, complete the following: 

Is the insurance now applied for intended to replace, in whole or in part, any 

insurance on your life or, if applicable, the life of your spouse or dependent? Yes No 

If “YES”, list the full name of the insurance company, and the policy number of the policy to be replaced: 

Company (print): Policy Number: 

Spouse Information (Complete ONLY if you selected TERM LIFE INSURANCE for your spouse) 

First Name Middle Initial Last Name 

/ / 

Social Security Number Age Date of Birth State of Birth 

F M 

Gender 

READ, SIGN AND DATE BELOW 

I understand and agree that: � The information provided on this Enrollment Application is true and correct to the best of my knowledge. � The 

insurance requested on this Enrollment Application will become effective in accordance with the individual effective date information in the Certificate 

of Insurance or individual Policy; any amount subject to evidence of insurability will not become effective until approved by Reliance Standard. 

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 Application 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 for enrolled 

dependents confined to a hospital or at home. � Benefits are subject to terms and conditions of the Policy. � For a plan with age-banded rates, 

premiums increase as an employee (or spouse, if applicable) moves from one age band to the next. � If payroll deduction of premiums begins prior 

to Reliance Standard’s processing of this Enrollment Application, it does not mean coverage is in effect; premiums paid for coverage not issued will 

be returned. 

Please Note: During an approved enrollment, guaranteed issue (GI) amounts of life insurance will not require evidence of insurability provided this 

form is complete, signed and received by your employer during your enrollment period and: a) you are not a late applicant with respect to life 

insurance for yourself (and/or your spouse, if applicable); or b) during your present service with your employer or an affiliate, you (and/or your 

spouse, if applicable) have not, with respect to life insurance with Reliance Standard or an affiliate: had an application withdrawn; been previously 

declined; had coverage postponed; or voluntarily terminated; or c) the enrollment period is not one with specific GI / EOI rules. 

χ 

Employee’s Signature Date 

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing 

a false or deceptive statement is guilty of insurance fraud. 

RELIANCE STANDARD LIFE INSURANCE COMPANY ADMINISTRATIVE OFFICE: Philadelphia, PA 




SUPPLEMENT TO ENROLLMENT APPLICATION EVIDENCE OF INSURABILITY for TERM LIFE INSURANCE 

EMPLOYER: We do not accept faxed 

forms. Submit completed enrollment 

Archdiocese of Cincinnati 

Policy Number: VG 175294 

applications for insurance to: 

Reliance Standard 

P.O. Box 7818 

Philadelphia, PA 19101-7818 

BG 

RSO 

VG GI: 

000001 

Chicago 

$50,000/$10,000/$20,000/Yes 

IF YOU SELECTED TERM LIFE INSURANCE, this Evidence of Insurability form must be completed… 

� …if you selected an Amount for yourself and/or your spouse (if applicable) that is above the Guaranteed Issue limit. 

� …if you and/or your spouse (if applicable) is a late applicant. 

� …if, during your present service with your employer or an affiliate, you and/or your spouse (if applicable) have, with respect to life insurance 

with Reliance Standard or an affiliate: had an application withdrawn; been previously declined; had coverage postponed; or voluntarily 

terminated. 

� …if you are enrolling during an approved annual enrollment after your initial enrollment period or initial eligibility period and there are specific 

Guaranteed Issue/evidence of insurability rules. 

� If you are not entitled to spouse Guaranteed Issue because you did not apply for at least $50,000 for yourself. 

If you have any questions about completing this form, see your Benefits Administrator. 

INSTRUCTIONS: 

All sections must be completed to ensure accurate processing. PRINT IN BLUE OR BLACK INK. 

You must sign/date this form. Your spouse (if applicable) must also sign/date this form if you complete this form with respect to insurance you 

selected for him/her. 

EMPLOYEE INFORMATION 

/ / / / 

First Name Middle Initial Last Name Date of Birth Social Security Number Date of Hire 

HEALTH QUESTIONS 

Current (h)eight and (w)eight: Employee (h) (w) Spouse (h) (w) 

Primary Care Physician: 

(Full name, address, telephone) 

Employee 

Spouse 

Have you or your spouse (if applicable) had, been told you had/have or been treated for any of the following within the past five (5) years: 

1. Consultation with any physician or received any medical care, treatment or advice? YES NO 

2. To the best of your knowledge, any physical impairment or disease? YES NO 

3. Consultation, medical care, treatment or advice from any physician for AIDS, AIDS-related complex (ARC) or 

disorder of the immune system? 

YES NO 

4. A disease of the nervous, genito-urinary or digestive systems, heart or lungs, high blood pressure, diabetes, 

cancer or a tumor of any kind? 

YES NO 

If you answered “YES” to any of the above questions, give details in #5 below. 

5. 

Question # Person to Whom it Applies Illness or Nature of Injury Date 

(If you need more space, use a separate sheet of paper, sign and date it, check here and attach it to this page.) 

Physician’s Full Name (and address if 

different from Primary) 

LRS-9381-0906-EOI-OH CONTINUED ON REVISE SIDE ►►► 




READ, SIGN AND DATE BELOW 

I understand and agree that: � The information provided on this Evidence of Insurability form is true and correct to the best of my knowledge. 

� The insurance requested on the Enrollment Application will become effective in accordance with the individual effective date information in the 

Certificate of Insurance; any amount subject to evidence of insurability will not become effective until approved by Reliance Standard. 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 Application 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 for enrolled 

dependents confined to a hospital or at home. � Benefits are subject to terms and conditions of the Policy. � For a plan with age-banded rates, 

premiums increase as an employee (or spouse, if applicable) moves from one age band to the next. � If payroll deduction of premiums begins prior 

to Reliance Standard’s processing of the Enrollment Application, it does not mean coverage is in effect; premiums paid for coverage not issued will 

be returned. 

I acknowledge receipt of the “Notice Regarding Information Practices.” 

AUTHORIZATION: I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance 

company, organization, institution, person or the Medical Information Bureau (MIB) to release any information or record(s) on me or my health to be 

used in determining the acceptability of my application for insurance. I authorize any such information or record(s) to be released to Reliance 

Standard Life Insurance Company, its reinsurers or authorized representatives. I also authorize Reliance Standard or its reinsurers to make a 

brief report to the MIB. This authorization, or a photographic copy, shall be binding as the original and valid for a period not exceeding twelve (12) 

months from this date. I understand that I may elect to be interviewed if an investigative consumer report is to be prepared in connection with this 

application and that I am entitled to a copy thereof. I further understand that I (or my authorized representative) will be sent a copy of this 

Authorization upon request. 

Please Note: During an approved enrollment, guaranteed issue (GI) amounts of life insurance will not require evidence of insurability provided the 

Enrollment Application is complete, signed and received by your employer during your enrollment period and: a) you are not a late applicant with 

respect to life insurance for yourself (and/or your spouse, if applicable); or b) during your present service with your employer or an affiliate, you 

(and/or your spouse, if applicable) have not, with respect to life insurance with Reliance Standard or an affiliate: had an application withdrawn; been 

previously declined; had coverage postponed; or voluntarily terminated; or c) the enrollment period is not one with specific GI / EOI rules. 

X 

X 

Employee’s Signature Date 

Spouse’s Signature 

(Your spouse must sing/date if you completed this form 

with respect to insurance you selected for him/her.) 

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a 

false or deceptive statement is guilty of insurance fraud. 

Attach this form to your Enrollment Application. 

Submit both forms at the same time. 

Date 

Keep the “Notice Regarding Information Practices” for your records. 

RELIANCE STANDARD LIFE INSURANCE COMPANY ADMINISTRATIVE OFFICE: Philadelphia, PA 




NOTICE REGARDING INFORMATION PRACTICES 

In considering this Application, Reliance Standard Life Insurance Company (“we”, “us” or “our”) collects certain information about all 

proposed insureds (you” or “your”). The precise information vanes according to the amount and type of coverage you apply for. Generally, we 

seek information about your: (1) age; (2) occupation; (3) physical condition; (4) medical history; (5) hobbies; and (6) other relevant activities. 

You are the most important source of information, but we may also verify or collect information on you or your family from: (1) physicians; (2) other health 

care providers; (3) employers; (4) other insurers to which you have applied; (5) consumer investigative organizations; and (6) the Medical Information 

Bureau (“MIB”). 

The MIB is a not-for-profit organization of life insurance companies which operates an information exchange for its members. This information may 

alert us to a need for further investigation, but under MIB rules such information cannot be used: (1) either wholly or in part to increase the premium 

for insurance; or (2) to deny issuance of insurance. 

We may collect information by: (1) phone; (2) correspondence; or (3) personal contact. 

Information will be treated as confidential. Reliance Standard Life Insurance Company or its reinsurers may, however, with your authorization make a 

brief report to the MIB. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to 

such a company, the MIB, upon request, will supply such company with the information in its file. The information supplied to other member 

companies may alert them to a need for further investigation. 

In some circumstances, however, information may be released to third parties without your authorization (with the exception of the MIB). These 

include persons or organizations who are: (1) performing business functions for us; (2) conducting actuarial or scientific studies or audits; or (3) our 

reinsurers. We or our reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance 

coverage, or to whom a claim for benefits is submitted. Please be assured that although such disclosures may occur, they are not always or even 

often made. When a disclosure is necessary, only as much information as is reasonably necessary to achieve the intended purpose will be 

disclosed. 

You have the right to acquire and, if necessary, correct any personal information we or the MIB collect. Upon written request to us, we will within 30 

days of receipt: (1) inform you of the nature and substance of the recorded information; (2) permit personal viewing and copying of the information in 

our possession; (3) disclose the identities of those persons such information has been disclosed to within the last two years; and (4) provide you with 

procedures for correction, amendment or deletion of the recorded information. Medical information will be disclosed to a physician that you choose. 

You may write to us for a fuller explanation of our information practices. 

You may also contact the MIB via its website (www.mib,com) or by telephone to arrange for disclosure of any information it may have on you. The 

MIB’s toll-free telephone number is 866-692-6901 TTY 866-346-3642 for hearing impaired). If you question the accuracy of information in the MIB’s 

file, you may contact the MIB in writing and seek correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The 

address of the MIB’s information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184-8734. 

KEEP THIS NOTICE FOR YOUR RECORDS. 

Home Office: Chicago, Illinois 

Administrative Office: Philadelphia, Pennsylvania

keep this notice for your records. - Archdiocese of Cincinnati

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