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TMA Member Term Life Insurance

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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.

HIPAA Authorization

Authorization for the Release of Information. This authorization is intended to comply with the HIPAA Privacy Rule. Authorization for the Release of Information. This authorization is intended to comply with the HIPAA Privacy Rule. I authorize and instruct any health plan, physician, health care professional, hospital, clinic, laboratory, medical facility, pharmacy benefit manager, retail pharmacy, clearinghouse, data warehouse or other comparable organization that aggregates and maintains pharmacy data, or other health care provider that has provided treatment or services to me within the past 5 years (“My Providers”) to disclose my entire medical record and any other health information concerning me to The Prudential Insurance Company of America (“Prudential”) and through it, to its reinsurers, authorized agents and MIB, Inc. This includes information on the diagnosis and treatment of Human Immunodeficiency Virus (HIV) infection (In Vermont and Wisconsin, this information is excluded) and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes. I also authorize the MIB, Inc. to release any data it may have about me for coverage to Prudential. By my signature below, I acknowledge that any agreements I have made to restrict the disclosure of health information do not apply to this Authorization and I instruct any of My Providers to release and disclose my entire medical record without restriction, including without limitation any restrictions on health care items or services for which a health care provider has been paid out of pocket in full. This health information is to be disclosed under this Authorization so that Prudential may: 1) underwrite an application for coverage and make risk determinations; 2) administer coverage; and 3) conduct other legally permissible activities that relate to any coverage I have or have applied for with Prudential. This Authorization shall remain in force for 24 months following the date of my signature below, and a copy of this Authorization is as valid as the original. I understand that I have the right to revoke this Authorization in writing, at any time, by sending a signed request for revocation to The Prudential Insurance Company of America; Group Medical Underwriting, P.O. Box 8796, Philadelphia, PA 19176, Attention: Senior Medical Underwriting Consultant. I understand that such a revocation is not effective to the extent that Prudential has taken action in reliance on this Authorization or to the extent that Prudential has a legal right to contest a claim under the insurance contract or to contest the contract itself. I understand that any information that is disclosed pursuant to this authorization may be re-disclosed to other parties and will not be protected by the HIPAA Privacy Rule. (In Montana only, I may request a record of any subsequent disclosures of protected health information). I understand that if I refuse to sign this Authorization to release my entire medical record and any other health information concerning me, Prudential may not be able to process an application for coverage. I understand that I have the right to request and receive a copy of this Authorization.

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, including portions containing health information 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 thereunder 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.

Accelerated Death Benefit option is a feature that is made available to group life insurance participants. It is not a health, nursing home, or long-term care insurance benefit and is not designed to eliminate the need for those types of insurance coverage. The death benefit is reduced by the amount of the accelerated death benefit paid. There is no administrative fee to accelerate benefits. Receipt of accelerated death benefits may affect eligibility for public assistance and may be taxable. The federal income tax treatment of payments made under this rider depends upon whether the insured is the recipient of the benefits and is considered terminally ill. You may wish to seek professional tax advice before exercising this option.

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 tenth 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.

Group Life and Disability Income Medical Underwriting Notice
Thank you for choosing The Prudential Insurance Company of America (Prudential) for your insurance needs. Before we can issue coverage, we must review your Enrollment Form. To do this, we need to collect and evaluate personal information about you. This notice is being provided to inform you of certain information practices Prudential engages in, and your rights with regard to your personal information. We would like you to know that: personal information may be collected from persons other than yourself or other individuals, if applicable, proposed for coverage; this personal information as well as other personal or privileged information subsequently collected by us may, in certain circumstances, be disclosed to third parties without authorization; you have a right of access and correction with respect to personal information we collect about you; and upon request from you, we will provide you with a more detailed notice of our information practices and your rights with respect to such information. Should you wish to receive this notice, please contact: The Prudential Insurance Company of America, Group Medical Underwriting, P.O. Box 8796, Philadelphia, PA 19176.

Any information we obtain regarding a person’s insurability will be treated as confidential. We may, however, make a brief report of it to the Medical Information Bureau (the Bureau), a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. When you apply for life, disability, or health insurance to any company, including Prudential, which is a member of the Bureau, or submit a claim for benefits to such a company, the Bureau will, on request, give the company the information in its files. In addition, upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If the information came from the Bureau and you question the accuracy of the information in the Bureau’s files, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The Bureau’s address is: MIB Group, Inc., Customer Service, 50 Braintree Hill Park, Suite 400, Braintree, MA 02184, 1-866-692-6901.

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.