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TMA Member AD&D Insurance

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Your eSignature Agreement

By signing the application electronically, you acknowledge that:

  • You have read, understood and agree to the Terms of Use as set forth in the link herein; and
  • You have read, understood and verify the accuracy of the information in the Enrollment Form; and
  • You agree that this electronic signature has the same full legal force and effect as a handwritten signature or mark.

eSignature Consent Notice

I agree to the usage of electronic signature and electronic records for current and future transactions pertaining to my application conducted through this website, effective on the date I click "Submit".

I understand that I have the option to print and retain paper copies of any electronic records generated and to obtain paper copies of any electronic records generated during website transactions concerning my coverage(s).

I understand that to obtain paper copies of electronic records kept by Prudential concerning my coverage(s), or to withdraw my consent to the usage of electronic records, I must contact Prudential through any of the means provided.

I understand that in the event my personal contact information changes, I must immediately notify Prudential of the changes through any of the means provided in the "Help" section of this website.

I understand that to access and conduct transactions relating to my coverage via any prudential.com Internet site, I must have access to a personal computer at my home or workplace which can support Internet access, and a compatible browser.

I represent that all statements and answers made within or attached to this Request Form are true and compliance to the best of my knowledge and belief. BY CHECKING THE BOX BELOW, YOU ACKNOWLEDGE THAT YOU AGREE TO THE ELECTRONIC DELIVERY OF THE AGREEMENT AND TO BE LEGALLY BOUND, WITH RESPECT TO THIS AGREEMENT, AS IF YOU HAD SIGNED THIS AGREEMENT WITH A HAND-WRITTEN SIGNATURE. YOU MAY PRINT OR RETAIN A COPY OF THIS AGREEMENT FOR YOUR RECORDS.

Important Notices

Statement of Understanding: I represent that all statements and answers made within or attached to this Request Form are true and complete to the best of my knowledge and belief. I understand that my request for coverage form are submitted to the Plan Administrator, acting for the policyholder, and that the administrator shall forward the request for coverage form to the insurance company. Furthermore, I understand that coverage shall be in effect only after these conditions have been met, this request for coverage form has been approved by Prudential; the Certificate has been issued while all persons to be insured there under are alive; the answers and statements in this request for coverage form continue to be true and complete until the Effective Date; and the initial premium contribution has been paid. I also understand that coverage will not take effect if the facts have changed. I have also read and understand and agree to the additional terms, conditions and requirements as stated in the Authorization for the Release of Information and Important Notice sections. I understand that completion of this request for coverage form in no way implies that I will be accepted for insurance coverage.

I certify that I have read, or have had read to me, the completed request for coverage form and I realize that any false statement or misrepresentation in the request for coverage form may result in loss of coverage under the Group Contract. By my signature below, I hereby request coverage. I acknowledge that I am a member, or Spouse/Domestic Partner to the member of the Association and that I must continue such membership to keep this insurance in force.

Important Notice: Fraud Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he/she is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive, or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is or may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for misleading, information concerning any fact material thereto.

Beneficiary Designation: If more than one beneficiary is desired, please write their name(s) and relationship(s) on a separate sheet and submit to the Plan Administrator. If more than one primary beneficiary is designated, settlement will be made in equal shares to the designated beneficiaries (or beneficiary) who are then still living, unless their shares are specified. If there is no named beneficiary, or no beneficiary survives the insured, settlement will be made in accordance with the terms of your Group Contract.

Electronic Fund Transfer Authorization: TMA Insurance Trust Automatic Insurance Payment Program Agreement provides for Electronic Fund Transfer for making your insurance payment without the use of a check. Your signed authorization is required. The electronic debit will occur on the fifth of each month that the payment is due. If the transfer falls on a weekend or bank holiday, your checking/savings account will be charged the next business day. The amount of the automatic debit may vary due to changes in the amounts of insurance or a premium contribution change. You will be notified in advance of changes to the amount of your debit due to premium contribution changes.

This request for coverage form is to be attached to and made part of the Group Contract.

Please keep this notice for your records.

I authorize the eSignature and have read and understand the terms and requirements of all the important notices.

By checking this button, I acknowledge that:

I read, understand and agree with all of the following statements: I declare that, to the best of my knowledge and belief, the responses I provided on the Health Statement for myself and if applying for Spouse/Domestic partner are complete and true. Prudential reserves the right to request additional health information from my Spouse/Domestic partner on the basis of the responses I provided to the questions.

Warnings
validation warnings here.