Professional Documents
Culture Documents
of Ohio Administrative Office: 4333 Edgewood Road NE Cedar Rapids, Iowa 52499 Home Office: Columbus, Ohio
May 31, 2012 CHRISTINA HIENG GAWRON 723 N IDAHO ST SAN MATEO, CA 94401-1120 USA
Policy Number: 013916070 Dear CHRISTINA HIENG GAWRON, Thank you for your recent inquiry to our Customer Service Department. Attached are the following documents, as requested: * Reinstatement CA We appreciate this opportunity to be of service. If there is anything else we can do to assist you, please call us at the number below. Thank you, Customer Service 800-851-9777
For your ease of reference, were providing this information from our records. We cannot assume responsibility for information that has not been provided to the Home Office, nor can we guarantee the validity or sufficiency of any documents, which have been provided to us. Western Reserve Life Assurance Co. of Ohio Cedar Rapids, IA 52499
MGIACOBBE
Western Reserve Life Assurance Co. of Ohio Administrative Office: 4333 Edgewood Road NE Cedar Rapids, Iowa 52499 Home Office: Columbus, Ohio
To:
Policy Services
Fax #: Re:
(727) 299-1620
REINSTATEMENT CA
For Review Please Comment
Urgent
Comments:
Western Reserve Life Assurance Co. of Ohio, P.O. Box 5068, Clearwater, Florida 33758
If additional space is necessary for CIRs, list childs name and date of birth on a separate sheet of paper.
YES s YES s
NO s NO s
YES s YES s
NO s NO s
Give details to all YES answers above. Please indicate person(s) to which details apply, dates of visit, reason for visit and findings. Give us the doctor, hospital, clinic, or health care providers full name and address. Proposed Insured: Question number: Reason for visit: Dates of visits: Findings: Proposed Insured: Question number: Reason for visit: Dates of visits: Findings: Proposed Insured: Question number: Reason for visit: Dates of visits: Findings:
Dr./Clinics address:
Dr./Clinics address:
Dr./Clinics address:
RA00100-CA
8) Does any proposed insured listed in Part 1 participate in aviation or any organized hazardous sport or activity? YES s If yes, complete an aviation or hazardous sports questionnaire and attach to application. 9) Will any proposed insured listed in Part 1 travel outside the United States within the next 12 months? If yes, provide details of when, where,and length of time._________________________________________ _______________________________________________________________________________________ YES s
NO s NO s
PART 4. REPRESENTATIONS
I represent that the statements and answers in this application are true and complete to the best of my knowledge and belief. It is agreed that: (a) The statements and answers given in this application, and any amendments or application supplements to it or statements made to the medical examiner, will be the basis of any reinstatement granted or insurance issued. (b) No agent or medical examiner has the autho rity to make or alter any contract for the Company. (c) No reinstatement will be effective or coverage provided until the date the application is approved by the company. (d) If a premium deposit is given, no insurance shall take effect until the application is approved by the company while all persons shown in Part 1 are living and their health remains as stated in the reinstatement and policy change application. (e) If a premium deposit is not given,no insurance shall take effect until the application is approved by the company and accepted by the owner, all premiums due have been paid and while all persons shown in Part 1 are living and their health remains as stated in the reinstatement and policy change application. (f) I further agree that this application will be attached and shall be ma de a part of the contract for insurance.
RA00100-CA
I also hereby authorize Western Reserve Life Assurance Co. of Ohio to provide its affiliated companies any and all information provided herein and obtained he reafter on me. This authorization shall be valid from the date signed below until affirmatively withdrawn in writing by myself. s I elect not to have personal information disclosed to non-affiliates of Western Reserve Life Assurance Co. of Ohio for marketing purposes. s I elect to be interviewed if an investigative consumer report is prepared in connection with this application. Signed at _____________________________________(city)________ (state)____________ on _________________(date)
__________________________________________________ Signature of Primary Insured or Proposed Insured (if over age 15 must sign) __________________________________________________ Signature of Spouse (if applicable)
RA00100-CA
Life Investors Insurance Company of America Monumental Life Insurance Company Stonebridge Life Insurance Company Transamerica Life Insurance Company Western Reserve Life Assurance Co. of Ohio
4333 Edgewood Road NE, Cedar Rapids, IA 52499
This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
Name of Primary Proposed Insured/Patient ______________________________________________________________ Name of Secondary Proposed Insured/Patient ______________________________________________________________ Name(s) of Unemancipated Minors Date of birth ________________________ Date of birth ________________________ Date(s) of birth Last four digits of SSN ____________________ Last four digits of SSN ____________________ Last four digits of SSN(s)
______________________________________________________________ ________________________ ____________________ I hereby authorize the use or disclosure of health information, as described below, about me or my above-named unemancipated minor children and revoke any previous restrictions concerning access to such information: 1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including the Companies noted above (the Companies)], insurance support organization such as MIB Group, Inc., or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children. 2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Companies, their affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Companies and their affiliates and reinsurers to redisclose the information to MIB Group, Inc., which operates an information exchange on behalf of life and health insurance companies. 3. Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor childrens insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, communicable or infectious conditions, such as AIDS (except HIV exposure/testing), and use of alcohol, drugs and tobacco including alcohol or drug abuse treatment. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records. 4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Companies and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.
_____________________________________________________________________________ Signature of Primary Proposed Insured/Patient or Personal Representative _____________________________________________________________________________ Signature of Secondary Proposed Insured/Patient or Personal Representative
If signed by an individuals personal representative or the parent or guardian of an unemancipated minor, describe authority to sign on behalf of the individual: Parent Legal guardian Power of Attorney Other (please describe): _____________________________________ (NOTE: If more than one individual is named above, please specify the individual(s) to which the personal representative applies.) Policy or contract number (if known): ________________________________________________ A copy of this authorization will be considered as valid as the original.
HIP 1207 CA Please return this original copy to Company
Life Investors Insurance Company of America Monumental Life Insurance Company Stonebridge Life Insurance Company Transamerica Life Insurance Company Western Reserve Life Assurance Co. of Ohio
4333 Edgewood Road NE, Cedar Rapids, IA 52499
This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
Name of Primary Proposed Insured/Patient ______________________________________________________________ Name of Secondary Proposed Insured/Patient ______________________________________________________________ Name(s) of Unemancipated Minors Date of birth ________________________ Date of birth ________________________ Date(s) of birth Last four digits of SSN ____________________ Last four digits of SSN ____________________ Last four digits of SSN(s)
______________________________________________________________ ________________________ ____________________ I hereby authorize the use or disclosure of health information, as described below, about me or my above-named unemancipated minor children and revoke any previous restrictions concerning access to such information: 1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including the Companies noted above (the Companies)], insurance support organization such as MIB Group, Inc., or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children. 2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Companies, their affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Companies and their affiliates and reinsurers to redisclose the information to MIB Group, Inc., which operates an information exchange on behalf of life and health insurance companies. 3. Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor childrens insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, communicable or infectious conditions, such as AIDS (except HIV exposure/testing), and use of alcohol, drugs and tobacco including alcohol or drug abuse treatment. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records. 4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Companies and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.
_____________________________________________________________________________ Signature of Primary Proposed Insured/Patient or Personal Representative _____________________________________________________________________________ Signature of Secondary Proposed Insured/Patient or Personal Representative
If signed by an individuals personal representative or the parent or guardian of an unemancipated minor, describe authority to sign on behalf of the individual: Parent Legal guardian Power of Attorney Other (please describe): _____________________________________ (NOTE: If more than one individual is named above, please specify the individual(s) to which the personal representative applies.) Policy or contract number (if known): ________________________________________________ A copy of this authorization will be considered as valid as the original.
HIP 1207 CA Applicants should retain this signed copy for their records