ALA ALLEGIANCE ACCIDENT
INSURANCE PLAN
(ALLEGIANCE ACCIDENT
PROTECTION PLAN)-
ONLINE ENROLLMENT
Underwritten by Hartford Life and Accident Insurance Company, Hartford, CT 06155

*Member Number:

* Years of Membership:

* First Name:

MI:

* Last Name:

* Gender:

*Date of Birth: (mm/dd/yyyy)

* Coverage Option

Individual: $32.50 Semi-Annually

Family*: $52 Semi-Annually

* Address:
Address 2:
Address 3:

* City:

* State:

Coverage is not available in following states/territories-AK, HI, IA, LA, MT, NM, NC, PR, OR, UT & WA

* Zip-Code:

*Email: Phone:

* How do you want to pay?

By Check

Semi-Annual Automatic Bank Withdrawal (Electronic Funds Transfer)

Please choose your payment plan

You will be invoiced.

Bank Account Information

* Name: * Bank Institution Routing Number: * Account Number: * Bank Account Type * What day would you like the draft to occur?

Your account will be debited on the day you choose, however your coverage will be effective the 1st day of the month following receipt of this completed enrollment form. Example: You chose a draft day of the 5th, your form was received by AmWINS Group Benefits on 03/16/2019, therefore your coverage is effective 04/01/2019. Your draft would occur on the 5th of each month with your first draft on 04/05/2019.

I authorize the Administrator to initiate debit entries for my regular payment from the bank account provided above. I understand that payment will be processed on or after the due date and will continue to be charged or deducted from my account unless I notify the Administrator otherwise in writing or my coverage ends. I also understand if corrections of the debit are necessary, this may involve an adjustment to my account.

I want to start enjoying the insurance coverage. Please send me my Certificate of Insurance reflecting the coverage available to me as a loyal Member. I understand that my coverage will take effect the 1st of the month following receipt of this completed Enrollment Form along with my first premium payment.

As a member I have read and accepted the terms.

Member Number:

Years of Membership:

First Name:

MI:

Last Name:

Gender:

Date of Birth:

Coverage Option

Address: Address 2: Address 3:

City:

State:

Zip-Code:

Email: Phone:

How do you want to pay?

By Check

You will be invoiced.

Semi-Annual Automatic Bank Withdrawal (Electronic Funds Transfer)

Bank Account Information

* Name: Bank Institution Routing Number: Account Number: Account Type What day would you like the draft to occur?

[Yes] I authorize the Administrator to initiate debit entries for my regular payment from the bank account provided above. I understand that payment will be processed on or after the due date and will continue to be charged or deducted from my account unless I notify the Administrator otherwise in writing or my coverage ends. I also understand if corrections of the debit are necessary, this may involve an adjustment to my account.

[Yes] I want to start enjoying the insurance coverage. Please send me my Certificate of Insurance reflecting the coverage available to me as a loyal Member. I understand that my coverage will take effect the 1st of the month following receipt of this completed Enrollment Form along with my first premium payment.

[Yes] As a member I have read and accepted the terms.

This valuable ALA Allegiance Accident Protection Plan is provided under Master Policy (ADD-13256).
*Family coverage is a percentage of your coverage. Please see summary for details.

The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life and Accident Insurance Company, Hartford, CT 06155.

Accident Form Series includes GBD-1000, GBD-1300, or state equivalent.

Fraud Notice(s)

For Residents of Florida:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

For Residents of Kentucky:
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 insurance act, which is a crime.

For Residents of Louisiana:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

For Residents of Maryland:
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

For Residents of New Jersey:
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an application for insurance is subject to criminal and civil penalties.

For Residents of New York:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

For Residents of Virginia:
Any person who, with the intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law.

* fill out all required items to proceed

ALA-ENROLL