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Critical Illness Disclosure Statement

The following statements must be reviewed carefully and signed as indicated:

Yes, as the primary applicant, I would like to apply for Critical Illness Coverage
Yes, my spouse would like to apply for Critical Illness Coverage
No, I do not want to apply for Critical Illness Coverage
No, my spouse does not want to apply for Critical Illness Coverage
I the undersigned, have been shown the Critical Illness protection offered to me by our USA Benefits Group agent. I understand that I am declining the lump sum benefit to be paid to me in the event of a critical illness and that I will be responsible for my health insurance deductible as well as any out of pocket expenses incurred for time off work due to such an illness.

Further, I choose to decline the guaranteed renewable life insurance benefit offered as part of this critical illness insurance. I have had the coverage and benefits explained to me and choose not to participate at this time.



Accident Coverage Disclosure Statement

Yes, as the primary applicant, I would like to apply for Accident Coverage
No, I do not want to apply for Accident Coverage
I the undersigned have been shown the 24 Hour Accident coverage offered to me by our USA Benefits Group agent. I understand that I am declining the additional benefit to help offset my major medical deductible in the event of an accident and that I will be responsible for my health insurance deductible as well as any out of pocket expenses incurred as a result of an accident.

By typing my full name in both of the boxes to the right, I am making an electronic signature certifying that I have completely read and understand the terms above.

Please enter your full name in both of the boxes to the right. This will serve as your electronic signature.

View the "Electronic Signatures in Global and National Commerce Act"

Primary Applicant's Fulll Name:
Re-Enter Primary Applicant's Fulll Name:
Secondary Applicant's Fulll Name:
Re-Enter Secondary Applicant's Fulll Name:
* Agent is required to obtain all necessary signatures.