Administration Guide for Reliance Standard Policyholders

Administration Guide for Reliance Standard Policyholders

GR 6012 RSL 5-20

WelcomeThank you for selecting Reliance Standard Life Insurance Company as the insurance carrier for your group. We're proud to be part of your benefits program, and we'll make benefits administration easy for you.

This booklet is a quick and easy guide to help you and your employees begin using your new benefits. Once you log in to your benefits administrator portal, everything you need will be at your fingertips. Let's get started!

Contact Us

Administration

Toll Free: 800-497-7044 Fax: 402-467-7338 Monday-Thursday: 7 a.m. to 7 p.m. CSTFriday: 7 a.m. to 5:30 p.m. CST

Reliance Standard P.O. Box 82510 Lincoln, NE 68501

Email: [email protected]

Take advantage of your benefits administrator portal and online services by completing and submitting our online eServices Agreement.

Billing payments

Reliance Standard P.O. Box 650804Dallas, TX 75265-0804

Please include the first page of your billing statementwith payments by mail. Make checks payable to Reliance Standard Life Insurance Company

Or, sign up for EFT payments with our online services. If you prefer to set up ACH/wire payments, please contact us.

Claims and benefits

Toll free: 800-497-7044Fax New Claims: 402-467-7336Fax Additional Info: 402-309-2580Monday-Thursday: 7 a.m. to Midnight CSTFriday: 7 a.m. to 6:30 p.m. CST

Reliance Standard P.O. Box 82510Lincoln, NE 68501

Email: [email protected]

Members can create their secure member account and get full access once they have a submitted and paid claim.

Provider networks

Based on your plan, here’s how to find dental and/or vision network providers in your area.

Find a dental provider: dentalnetworkpartners.ameritas.comOr call Reliance Standard: 800-497-7044

Find a VSP vision network provider: vsp.comOr call VSP: 800-877-7195

Find an EyeMed vision network provider: eyemed.comOr call EyeMed: 866-289-0614

For Reliance Standard vision plans offering the VSP and/or EyeMed provider networks, Reliance Standard is your contact for plan administration.

http://www.employeebenefitservice.com/partners/findprov.asp

https://www.vsp.com/

https://eyemed.com/en-us

Quick Start Guide

Look for a welcome email from Reliance Standard to help you get set up and begin using your new benefits. To get started, just complete these 2 simple steps:

1. Review your certificate(s) and master policy. Your plan rates are listed in your master policy under 9050 – Table of Monthly Premiums.

2. Post or distribute our Privacy Notice to plan participants. Notices are available in English and Spanish in this guide and at reliancestandard.com/dental-vision.

Now you’re ready to set up your benefits administrator portal and activate your online services. Check out the interactivetutorial at reliancestandard.com/dental-vision, Benefits Administrator, eServices Tutorial. If your policy was sold with eCert, you already have access to your certificate(s), policy and ID cards.

http://www.reliancestandard.com/dental-vision

http://reliancestandard.com/dental-vision

http://www.employeebenefitservice.com/gmr/demo/

Activate Additional Online Services

View your ID cards, policy and certificate(s), plus make enrollment updates and pay your bill online, through your secure benefits administrator portal. If your policy was sold with eCert, you automatically received an authorization ID for signing in. If not, we will email this information to you once you complete and submit our eServices Agreement. If you already have eCert, complete and submit our eServices Agreement to add enrollment and billing access.

• Fill out the online eServices Agreement at reliancestandard.com/dental-vision.

• Select the Submit This Agreement button.

• If you need assistance setting up your secure benefits administrator portal for online services, please call us at 800-497-7044.

EDI, an electronic enrollment file process, is available to qualifying groups.

eServices Agreement Account Access page

Benefits Administrator portal

https://wf.employeebenefitservice.com/dental/benadmin.asp?pres=rsl

https://wf.employeebenefitservice.com/wps/portal/s136/Home/ba/eservices/!ut/p/z1/nZFPD4IwDMU_iweO0iIG0ds4iCH-jwTcxUyYsASGGVO-vhgvmigae2vz3q9pH1CIgUp2FRnTopKsaPs9dQ6jjeXMxkNc-GRuI1lPA99fepa7RIg6BTsL6C9-fCmC3nbg2Yj-avCP_5n0m79DQLvxEdDOFfcPvGG8nvhtSQA0K6rjIw8ij7abAVX8xBVX5kW141zr88RAA5umMRUvBJMJrzWTKVOpmVSlgSmXmhX9q6jbaA18h8qrWkP8CQHnMgzDGMW6jNya9Ho3fytMnA!!/dz/d5/L2dBISEvZ0FBIS9nQSEh/



http://reliancestandard.com/dental-vision

Manage Your Plan

Online servicesUsing the online services through your benefits administrator portal makes administering your employee benefit plan fast and easy. Once it’s set up, get there by visiting reliancestandard.com/dental-vision, Account Access, Dental/Vision, Benefits Administrator.

Certificate, policy (eCert)• view or print your certificate(s), policy and ID cards• distribute certificates electronically or post on your benefits intranet• employees may view and print their own copy of the certificate, giving them direct access to benefit information• or, benefits administrators can print certificates for employee reference• see the most current documents for your plan, including updates

Enrollment (eEnroll)• enroll, change or drop employee coverage in real time• view employee coverage status including effective dates, dependent coverage levels• sign up for eEnroll and you’re eligible for eBill

Billing and EFT (eBill)• request your bill online, pay online• update member, dependent information before paying• view or print a list billing that shows your detailed adjustments• access a year of premium information and billing history

Eligibility for plan enrollmentEmployee eligibilityEligibility requirements are defined in your policy under 9070 – Conditions for Insurance Coverage. The eligibility period, also known as the new hire waiting period, begins when the member meets the policy’s requirements; for example, working at least 30 hours per week. When the eligibility period is satisfied, the member’s coverage becomes effective.

Dependent eligibilityThe member’s eligible dependents include:

• member’s spouse (or domestic partner if this coverage is elected)• each child under the age defined in your policy (see 9060 – Definitions) who is the member’s or member’s spouse’s legal

responsibility, including:– natural born children– adopted children, eligible from the date of placement for adoption– children covered under a Qualified Medical Child Support Order as defined by applicable federal and state laws

• each child who is:– a full-time student at an accredited school or college; and– primarily dependent on the member or member’s spouse for support and maintenance

A divorced spouse is not eligible, but a spouse who is separated from the member is eligible.

Over-age child dependentsPlease notify us when child dependents reach the age when they no longer can be considered a dependent. Otherwise, we will not know until a claim is submitted and the claim unfortunately is denied. To avoid this, you can run an over-age dependent report and update dependent coverage as necessary using your online services. In your policy, please review 9060 – Definitions to determine the dependent age limitation for a child and/or full-time student.

Table of Contents• Online services• Eligibility• Enrollment• Effective dates• Drop plan members• Policy changes• Section 125 plans• Monthly plan payments• Benefits for non-eligibles• Continuation of benefits• Claims, member account• Forms (also online)• Employee well-being support


Please review your policy for specific eligibility requirements. If you have questions, please call us at 800-497-7044.

Enroll plan members, dependentsTo add/update/drop member or dependent coverage using your activated online services, visit reliancestandard.com/dental-vision, Account Access, Dental/Vision, Benefits Administrator. Then sign in to your online portal.

If you have not yet activated your benefits administrator portal and online services, please have the employee fill out an Reliance Standard enrollment/change/waiver form available in this guide or at reliancestandard.com/dental-vision, Forms. We’ll keep the original enrollment form, so if you need a copy for your records, please make one before submitting it.

Mail, fax or email enrollment forms to:Reliance Standard Life Insurance CompanyP.O. Box 82510Lincoln, NE 68501-2510Fax: 402-467-7338Email: [email protected]

Incomplete information or missing signatures may delay enrollment. In addition, the employee needs to elect coverage within 31 days of becoming eligible to avoid possible late entrant limitations. Please see 9060 – Definitions in your policy to determine if late entrant provisions apply.

The member’s ID card and/or certificate of coverage will be available after the member is enrolled. Once the member’s first claim is submitted and paid, members can opt to go paperless and receive their Explanation of Benefits (EOB) statements online. All they need to do is create their secure member account at reliancestandard.com/dental-vision, Account Access, Dental/Vision, Member, Secure Member Account.

Same employer spouse provisionThis applies to a married couple who are both employed by your company and have eligible dependent children. It allows for one spouse to carry the employee coverage and the other spouse to be covered as a dependent along with the children. See 9070 – Conditions for Insurance Coverage in your policy to determine if this is included in your plan.

Total disabilityThis describes a dependent who is continuously incapable of self-sustaining employment because of mental or physical handicap and chiefly dependent upon the member for support and maintenance.

Dependent exceptionsWe may make exceptions for dependents who are not natural born, adopted or stepchildren of the member, but who do meet the dependent age requirement in your policy under 9060 – Definitions. Exceptions may include when the:

• member has legal guardianship of the dependent• dependent is covered by the member’s medical carrier • member legally claims the dependent at tax time

For dependents, note the following on the form:

• reason for the change• date the dependent qualified for coverage• and/or date the dependent coverage should end


https://customercare.rsli.com/dental-vision/

https://secure.rsli.com/userservices/Default.aspx

Effective datesThe effective date for members and their covered dependents is based on the following. The eligibility period also is known as the new hire waiting period. Please note, some policies do not allow employees to waive coverage for themselves or their dependents.

If the enrollment form is signed The member’s effective date is*

on or before the eligibility period is satisfied the date the eligibility period is satisfied

within 31 days after the eligibility period is satisfied the date the enrollment form is signed

over 31 days after the eligibility period is satisfied the date the enrollment form is signed**

*Some policies are written with first-of-the-month effective dates. Coverage for these policies becomes effective on the first of the month following the date the member becomes eligible.

**Check your policy to see if late entrant limitations apply.

Employee hired

April 5

Enrollment form distributed

April 5-July 31

Eligibility period ends

July 5(90 days

per employee)

Enrollment submission

July 6-July 31

Effective date

August 1

ExceptionsIf employment is the basis for plan participation, an employee needs to be in active service on the date the insurance, or any increase in insurance, takes effect. Otherwise, the insurance will not take effect until the day the employee returns to full-time active service.

Reinstatement or rehiresIf employment is the basis for plan participation, a member whose eligibility terminates and is re-established may need to complete a new eligibility period. However, if the person is rehired within 12 months from the original termination date, there’s no waiting period. On the enrollment/change form, include the date of rehire after the Rehire check box.

Sample of a 90-day eligibility period

Drop plan members, dependentsTo add/update/drop member or dependent coverage using your activated online services, visit reliancestandard.com/dental-vision, Account Access, Dental/Vision, Benefits Administrator. Then sign in to your online portal.

Outside of your benefits administrator portal, you can:

• list terminated members on page 1 of the premium statement, and note the last day worked• draw a line under the member’s name on the itemized listing, and note the last day worked• call our administration and billing department toll free at 800-497-7044• complete an enrollment form, note the last day worked, and mail or fax it to Reliance Standard Customer Service

Please note that coverage ends on the date the member ceases to be an eligible member, unless your group policy contains an end-of-month provision. The member’s termination date excludes accrued vacation time or similar benefits. There’s no refund when termination occurs in the middle of a policy month, so the premium should be paid for the full month.

Be sure to report member terminations as quickly as possible. Without current member eligibility information, we may inadvertently pay claims for expenses incurred after the member or dependent’s termination date. If this happens, we may require additional premium from your company to cover it. Please refer to your policy under 9050 – Simplified Accounting for more information.

Some members may be eligible for a continuation of coverage through COBRA. Or, you can offer them our individual dental or vision plans. Please see the information in this guide.


Policy changesPolicy changes you may need to make include:

• company name change• eligibility period change• number of weekly work hours members need to qualify for coverage• adding additional Reliance Standard benefits, such as dental or vision

To make policy changes, please inform your Reliance Standard representative or your benefits broker, and send us a letter outlining your request. Some updates may require additional underwriting and impact your rates.

In your letter:

• outline your desired plan change• include your requested effective date• submit it in writing on your company letterhead • make sure the letter is signed by a person authorized to represent your company• mail, fax or email your letter to Reliance Standard Group Administration

Section 125 PlansDetails about Section 125 requirements can be found under IRS 26 U.S. Code § 125 and supporting treasury regulations. Please consult your tax advisor for more information and advice regarding “cafeteria plans.”

Section 125 of the IRS code allows employees to purchase benefits on a pre-tax basis. These plans are sometimes referred to as cafeteria plans. The premium usually is paid by the employee, although the employer may contribute to the premium. Section 125 plans have an annual election period each year for employees to elect the benefits they want for the coming plan year.

Eligibility for plan enrollmentSection 125 plan enrollment or termination is allowed only:

• when a new hire’s eligibility period is satisfied• during the annual election period• when a member experiences a life event such as marriage, divorce, death, birth or adoption, termination of employment

Please note, the annual election period is not an open enrollment. Applicable late entrant penalties would apply based on your policy. The plan year is any 12-month period selected by the employer. Calendar year is the most common.

Family status changeQualifying life events allow an employee to make mid-plan-year changes outside of the annual election period. Examples include marriage, divorce, birth of a child, death of a spouse or child, and spouse’s termination of employment.

Annual election periodIf an employee does not elect to participate when initially eligible, the employee may elect to participate at the next annual election period. A member also may elect to cancel coverage or reinstate coverage that was canceled during a previous election period. Applicable late entrant limitations would apply to members or dependents who previously waived or canceled coverage. The election period selected is in your policy under 9070 – Conditions for Insurance.

Late entrant provisionA late entrant is an employee or dependent who does not enroll within 31 days of becoming eligible or who reinstates coverage after canceling. The benefits available would be limited for the amount of time outlined in your policy under 9219 – Limitations. In addition, the premium must be paid during this period and cannot be paid in one lump sum. Check your policy to verify if late entrant limitations apply.

Elect/change/drop members, dependentsWith Section 125 plans, employees and their dependents who do not elect coverage within 31 days of becoming eligible cannot enroll until the next annual election period and may be subject to late entrant limitations. Please review the 9219 – Limitations, and 9060 – Definitions, in your policy to determine if late entrant limitations apply.

Members can elect/change/drop coverage ONLY:

• within 31 days of the date the employee first becomes eligible, loses eligibility elsewhere, or experiences a qualifying life event • during the annual election period

If the member drops coverage for reasons other than termination of employment, the change needs to be reported.

Monthly plan paymentsPremium payments are due by the first day of the coverage period. If you do not receive your billing statement by the first of the current month, please contact us at 800-497-7044.

Late payments received after the last day of the billing cycle may result in termination of coverage and claims processing for your members. Please refer to 9050 – Premiums, and 9323 – Grace Period, in your policy.

Pay by checkPlease include the first page of your billing statement along with a check payable to Reliance Standard Life Insurance Corp. If you made enrollment adjustments, please show how you calculated your payment.

Mail your statement’s first page, check and adjustment calculations to: Reliance Standard Customer ServiceP.O. Box 650804Dallas, TX 75265-0804

Pay onlineYou may use Electronic Funds Transfer (EFT) even if you have not yet activated your benefits administrator portal’s online services. Once set up, your EFT payment will be paid automatically, withdrawing the total premium amount due each month.

Sign up for EFT• Access the EFT form using your activated online services. The form also is in this guide.• Provide a copy of a voided check from the bank account you’ll be using.• Mail both items to: Reliance Standard Life Insurance Company, P.O. Box 82510, Lincoln, NE 68501-2510

Premium calculationThe amount due appears on the first page of your billing statement and is determined as follows.

+/– Credit or balance forward

– Payment received

+ Current month’s premium due for active members

+/– Retroactive credit and/or debit adjustments reflecting enrollment updates

= Total amount due/check amount

Member termination adjustmentsPlease note, your premium will not be prorated for members who terminate between premium due dates. However, for retroactive terminations, from the date you notify us, you may qualify for a refund of unearned premium credit from the most current statement.

COBRA continuation of group benefitsTHIS INFORMATION REGARDING CONTINUATION AND COBRA IS PROVIDED FOR YOUR INFORMATION ONLY AND IS NOT LEGAL ADVICE. IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING WHETHER YOUR HEALTH PLAN IS SUBJECT TO COBRA CONTINUATION REQUIREMENTS, OR ANY OTHER QUESTIONS CONCERNING COBRA, SEEK THE ADVICE OF LEGAL COUNSEL. In circumstances where a member may elect COBRA, please submit the member’s last day worked in the same manner as all other terminations. Once the member has elected COBRA, follow the steps below to reinstate the member retroactive to their termination date.

COBRA enrollmentTo enroll a former member or covered dependent for continuation coverage under COBRA, please notify us by filling out an enrollment/change/waiver form and filling in the COBRA box near the top of the form. People choosing COBRA continuation have 60 days to elect the coverage.

When a member elects COBRA continuation of group benefits, you can reinstate that member retroactively to their termination date. Any claims that were denied during the termination period can be reconsidered as long as the provider or member calls us at 800-497-7044 and lets us know which claims require reconsideration.

COBRA coverage will end:

• at the end of 18 months for employee members*• at the end of 36 months for dependents, unless otherwise noted

Example: A terminated employee is eligible for a maximum of 18 months of COBRA coverage. A dependent spouse who loses coverage due to divorce can elect up to 36 months of coverage.

In addition, you must notify us if the person:

• has coverage for 18 months; notify us at the end of 18 months for an employee*• has dependents; notify us at the end of 36 months for dependents (except as noted above)• does not pay the premium• becomes eligible for Medicare benefits• remarries and becomes covered under another plan• terminates COBRA coverage; then submit the termination in writing to discontinue COBRA coverage; please note that

people who terminate COBRA coverage may not be reinstated

The Consolidated Omnibus Budget Reconciliation Act, or COBRA, became law on July 1, 1986. In general, the law requires a policyholder who employs 20 or more people to provide continuation of health care benefits to employees who lose their coverage due to a qualifying event. This includes being laid off, terminated, retired or fired for reasons other than gross misconduct. The law also allows continuation of benefits for dependents who lose coverage due to death of the member or divorce. Some states have insurance continuation legislation. These state laws, if applicable, would run concurrently with COBRA.

COBRA members can add/update/drop dependent coverage, but the coverage is limited to the continuation period. COBRA members are responsible for paying their premiums, and it’s important to know that we cannot accept personal checks from the member. The amount charged is based on the same rates charged for active/retired employees and their dependents. You may add 2 percent of the premium to the rate charged and retain that 2 percent fee to cover your administrative expenses. You would be responsible for collecting the member’s COBRA premium and including it with your regular premium payment.

* An employee who is disabled according to Social Security rules may be eligible for up to an additional 11 months.

Claims, member accountHelp your employees submit claims, and promote our secure member account portal where they can access all of their plan information. Members can create an account at reliancestandard.com/dental-vision, Secure Member Account.

Dental claimsTypically the dental provider will submit the member’s claim. If the member submits the dental claim form and wants payment made directly to the dental provider, the member can sign the authorization on the form. For a pre-treatment estimate of what the plan will pay, the dental provider can select the pre-treatment estimate checkbox on the dental claim form and submit it before the dental work begins.

Vision claimsYou may have an Reliance Standard vision plan with VSP or EyeMed network provider coverage. Or a no-network vision plan. VSP or EyeMed network providers typically submit the member’s claim. However, if the member goes outside of the VSP or EyeMed network, there is an out-of-network claim form to complete. With our Basic Vision no-network vision plans, members will need to submit an Reliance Standard vision claim form and include the provider’s itemized bill for reimbursement up to the plan benefit.

Secure member accountMembers may create their secure member account at reliancestandard.com/dental-vision, Secure Member Account. Members have access to their:

• ID cards• savings cards for prescriptions and eyewear,

if applicable• benefits summary and certificate of coverage

• claims status and remaining benefits• Explanation of Benefits (EOB) – They can elect to

go paperless • Dental Cost Estimator (dental plans)

Find forms online at reliancestandard.com/dental-vision, Forms.





You are welcome to download forms from reliancestandard.com/dental vision, Forms. Or use the printed forms that follow.

• GLB Privacy Notice – Post or distribute to plan participants available online under Privacy.

• Enrollment/change/waiver form – Dental, Vision/Eye Care

• Enrollment/change/waiver form – Dental

• Enrollment/change/waiver form – Vision/EyeCare

• State-specific enrollment/change/waiver forms available online under Forms

• EFT authorization form (available through your secure benefits administrator portal)

If you have questions or need assistance, please call our administration experts at 800-497-7044.

Forms


https://customercare.rsli.com/documents/dentalvision/REL-1.pdf

https://customercare.rsli.com/documents/dentalvision/REL1_D.pdf

https://customercare.rsli.com/documents/dentalvision/REL1_E_HL.pdf



RELIANCE STANDARD LIFE INSURANCE COMPANY

FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY

RELIANCE STANDARD LIFE INSURANCE COMPANY OF TEXAS

PRIVACY NOTICEThe Reliance Standard Life Insurance group of companies recognizes that protecting the privacy and security of the personal information we obtain about our customers is an important responsibility. This Privacy Notice generally describes our policy about how we treat that information. This notice refers to Reliance Standard Life Insurance Company, First Reliance Standard Life Insurance Company and Reliance Standard Life Insurance Company of Texas using the terms “we,” “us,” and “our.”

Information we may obtain. Depending on the type of product or service that we are providing, we may obtain Customer Information, Financial Information and/or Health Information about you.

Customer Information includes identifying information such as your name, address, telephone number, Social Security number and demographic data about you. It also includes information about your transactions with us such as the type and value of the Reliance Standard products you own and the amount of premiums and fees that you pay to us.

Financial Information includes information about your income, assets, liabilities, and the type and value of other insurance that covers you.

Health Information includes information about your health and medical history and your insurance underwriting risk factors.

Security of the information. We maintain physical, electronic and procedural safeguards that comply with Federal and State laws to protect all of the information we have obtained about you.

From whom we obtain information. We may obtain Customer Information, Financial Information and/or Health Information from any of the following sources:

• Your application and related forms

• Your insurance agent or broker

• Your communications with us

• Your employer

• Your medical providers

• Consumer reporting agencies

• Your claim for benefits

• Anyone you have authorized to provide

information to us

Please post or distribute to plan membersImportant notice of privacy of information practices

5

What we do with the information we obtain. The Customer Information, Financial Information and Health Information (collectively referred to here as “Information”) which we obtain is used in order to provide our products and services to you, and may be used to evaluate your request for products or services, evaluate your claim for benefits and process your transactions with us. We may also use the Information to offer you other products and services which we or our affiliated companies (that is, members of the Delphi Financial group of companies) provide. The Information may be disclosed to non-affiliated entities with whom we have contracted to perform certain business services for us. This may include entities which provide claims administration, underwriting, investigation, reinsurance, policyholder or other services to us or on our behalf. These companies are carefully selected, and are required by the terms of their contract with us to maintain the confidentiality of the Information. We may also disclose Information about you if you have authorized us to do so, or as otherwise permitted or required by law.

We do not disclose any nonpublic personal information about you to any non-affiliated company for marketing purposes or for any other purpose except as described in the previous paragraph.

Independent Sales Agents. Your policy may have been placed with us through an independent agent or broker (“Sales Agent”). Your Sales Agent may gather and retain Information about you. The use and protection of Information by your Sales Agent is your Sales Agent’s responsibility, not our responsibility. If you have questions about whether or how your Sales Agent uses or discloses such information, please contact your Sales Agent.

Important notice of privacy of information practices (continued)

6

RELIANCE STANDARD LIFE INSURANCE COMPANY

FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY

RELIANCE STANDARD LIFE INSURANCE COMPANY OF TEXAS

AVISO ACERCA DE LA PRIVACIDAD El grupo de compañías de The Reliance Standard Life Insurance reconoce que es una importante responsabilidad la protección de la privacidad e integridad de la información personal que obtiene de sus clientes. Este aviso acerca de la privacidad describe de manera general nuestros lineamientos acerca de cómo manejamos dicha información. Cuando este aviso menciona los términos “nosotros” y “nuestro”, se refiere a Reliance Standard Life Insurance Company, First Reliance Standard Life Insurance Company y Reliance Standard Life Insurance Company of Texas.

Información a obtener. Dependiendo del tipo de producto o servicio que proporcionemos, podremos obtener información acerca de usted como cliente, de su información financiera y/o médica.

La información como cliente incluye información acerca de su identidad, tal como su nombre, domicilio, teléfono, número de seguro social y datos demográficos acerca de usted. También incluye información acerca de las transacciones que ha realizado con nosotros, tales como el tipo y valor de los productos de Reliance Standard que posee y el monto de primas y tarifas que nos paga.

La información financiera incluye información acerca de sus ingresos, activos, pasivos, y el tipo y valor de otros seguros con los que tiene cobertura.

La información médica incluye información acerca de su salud, su historial médico y los factores de riesgo para la suscripción a una póliza de seguros.

Seguridad de la información. Contamos con procedimientos para salvaguardar física y electrónicamente la información que obtenemos acerca de usted, con el fin de cumplir con las leyes estatales y federales.

Fuente de la información. Podremos obtener información de usted como cliente, de su información financiera y/o médica por parte de cualquiera de las siguientes fuentes:• Su formulario de inscripción y documentos relacionados • Su agente o corredor de seguros • Los avisos o notificaciones que nos haya enviado • Su empleador • Sus proveedores médicos • Compañías de información crediticia • Sus reclamos de beneficios • Cualquier persona que usted haya autorizado para

proporcionarnos información

Sírvase compartir y distribuir a los miembros del plan este aviso importante acerca de las prácticas de privacidad de la información

1

Lo que hacemos con la información que obtenemos. La información como cliente, financiera y médica (en conjunto significa en este documento “Información”) que obtenemos se utiliza para proporcionarle servicios y puede usarse para evaluar su solicitud de productos y servicios, evaluar sus reclamos de beneficios y procesar sus transacciones. También podemos usar la información para ofrecerle otros productos y servicios los cuales sean proporcionados por nosotros o por nuestras compañías afiliadas (que son parte del grupo de compañías Delphi Financial). Se puede compartir la información con instituciones no afiliadas con las cuales tengamos un contrato para que desempeñen ciertos servicios comerciales para nosotros. Esto puede incluir instituciones que brinden servicios de administración, suscripción, investigación, reaseguro, para el titular de la póliza u otros servicios proporcionados por nosotros o en nuestro nombre. Estas compañías se seleccionan cuidadosamente y se les exige conforme a los términos de su contrato que cumplan con la confidencialidad de la información. También compartiremos información acerca de usted si nos da la autorización para hacerlo o si así lo permite o exige la ley.

No compartiremos con compañías que no estén afiliadas a nosotros, información personal acerca de usted que no sea pública con fines de mercadotecnia o cualquier otro propósito excepto lo descrito en el párrafo anterior.

Agentes independientes de ventas. Es posible que un agente o corredor independiente (“Agente de Ventas”) lo haya inscrito en una póliza con nosotros. Su agente de ventas puede recolectar y conservar información acerca de usted. El uso y protección de la información por parte de su agente de ventas es responsabilidad de dicho agente de ventas y no nuestra responsabilidad. Si tiene alguna pregunta acerca de cómo su agente de ventas usa o comparte la información, le pedimos se comunique directamente con su agente de ventas.

Aviso importante acerca de las prácticas de privacidad de la información (continuación)

2

Policy and Div. # 136- _____________________________

Cert. # ________________________________________ COBRA: If individual is a continuee:

Qualifying Event Date of Event

Name and Address of Employer (Policyholder)

1 to enroll Dental Eye Care To terminate all coveragesEmployee InformationMarital Status Single Married Civil Union* Domestic Partner* *As defined by state law or your Group.

Social Security number __________________________ Dept. number __________________________

Employee’s last name, first name, MI ____________________________________________________________________________________

Date of birth________________ Male Female Full time date of hire________________ Rehire: Rehire date ________________

Occupation ________________________________________ Hours worked each week_____ Are your earnings paid: Hourly or Salaried

Street address_____________________________________________ City__________________________ State_____ ZIP ____________

E-mail address (limit of 60 characters) ___________________________________________________________________________________Are you covered under another dental insurance plan? . . . . . . . . . . . . . . . . .Employee: Yes No Dependents: Yes NoAre you covered under another eye care insurance plan? . . . . . . . . . . . . . . . .Employee: Yes No Dependents: Yes No

Dependent Coverage Information List all eligible dependents to be added or deleted. (Employee must be enrolled to cover dependents)

Print full legal name (last, first. MI)Dental Eye Care

Relationship Sex Date of birth Social Security no.College

student?add drop add drop

1

2

3

4

5

Please Sign (employee/policyholder) The certificate provides dental and eye care benefits only. Review your certificate carefully.As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case of a life event. This information was explained in the plan’s solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate to the best of my knowledge. The policyholder certifies the date of employment, job title, hours worked and salary information are correct according to the Policyholder’s records.

XEmployee Signature (do not print) Date

XPolicyholder Signature (do not print) Date

In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or mislead-ing information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (State-specific statements on back.)

Employee late entrant date ______________________

Dependent late entrant date _____________________

Effective Date Class Dep. Code

2 to change Name Change New Name _________________________________________ Old Name____________________________________ Add Dependent Coverage

If due to marriage, what is the date of marriage?_____________ If due to birth/adoption, what is the date of event?____________________

If due to loss of coverage, date and reason: _________________________________________________________________________

If other, the date of event and please explain: ________________________________________________________________________

Drop Dependent Coverage Number of dependents still covered: ______ Effective date of drop: _______________________________ Due to divorce Due to death Due to annual election period Exceeds maximum age to qualify as dependent

Other (please explain) _________________________________________________________________________________________

3 to waive IF YOU DO NOT WANT COVERAGE, COMPLETE THE WAIVER SECTION. THE WAIVER MAY NOT BE ALLOWED FOR THIS PLAN, CHECK WITH YOUR EMPLOYER. I have been given an opportunity to apply for Group Insurance offered by my employer, and have decided not to accept the offer for:

myself (does not apply to TRUST policies) spouse/domestic partner child(ren) only spouse/domestic partner and child(ren)

because _________________________________________________________________________________________________________

Name of insurance company and employer of dependent _____________________________________________________________________Should I desire to apply for this group insurance in the future, I realize that a “late entrant” penalty may be applied.

REL 1 Rev. 05-11 Page 1 of 2 09-07-17

enrollment / change / waiver Group Insurance FormReliance Standard Life Insurance Company P.O. Box 82510, Lincoln, NE 68501-2510 / 800-497-7044 / Fax: 402-467-7338

Note for California Residents: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

For group policies issued, amended, delivered, or renewed in California, dependent coverage includes individuals who are registered domestic partners and their dependents.

No Cost Language Services. You can get an interpreter and have documents read to you in your language. For help, call us at the number listed on your ID card or 877-233-3797. For more help call the CA Dept. of Insurance at 800-927-4357.

Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al 877-233-3797. Para obtener más ayuda, llame al Departamento de Seguros de CA al 800-927-4357.Note for Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.Note for Florida Residents: 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.Note for Georgia, Kansas, Nebraska, Oregon, Vermont and Virginia Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.Note for Kentucky Residents: 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.Note for Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss of 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.Note for Maryland Insureds: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.Note for New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.Note for New Mexico: 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 civil fines and criminal penalties. This type of plan is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does not satisfy the individual mandate that you have health insurance coverage. If you do not have other health insurance coverage, you may be subject to a federal tax penalty. Note for Rhode Island Residents: 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 civil fines and criminal penalties.Note for North Carolina Residents: After 2 years from the date of issue or reinstatement of this policy, no misstatements made by the applicant in the application shall be used to void the policy or deny a claim for loss commencing after the expiration of such 2 year period.Note for Pennsylvania Residents: 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 subjects such person to criminal and civil penalties. Note for Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of coverage.Note for Texas Residents: Any person who knowingly and with intent to defraud provides false, incomplete or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, may be guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim.Note for Washington, D.C. Residents: 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.Note for Washington Residents: For groups policies issued, amended, delivered, or renewed in Washington, dependent coverage includes individuals who are registered domestic partners and their dependents.

tips for filling out this formTo EnrollMissing, incomplete or illegible information can cause delays in adding new employees to the system and could create errors in billing. To ensure proper handling of your enrollment forms, please make sure the following areas are completed:• Policy Name and Group Number – to make sure plan members are

added to the correct group.• Department/Division Numbers – so plan members are added in the

proper locations, and appear in the appropriate section on the billing if the group has multiple departments or divisions.

• Social Security Numbers – the most important identifier for plan members when calling in with claims or administrative questions. Please double check to make sure your social security number is accurate and written clearly.

• Full-time Employment Date – needed so the correct effective date is calculated for new members.

• Class Number – needed when the plan has more than one class of employees.

To ChangeChanging Dependent Codes – When adding or dropping dependents, please note whether this change is because of a “life event” or for some other reason. (Examples of life events: marriage, birth of a child, divorce…) Please remember to include the date of the event. Late entrant status will be applied if a life event is not included. Be specific when changing status so all dependents who are still eligible will be covered.

ImagingIn order to provide better service, our administration system utilizes image technology. In the image environment, we scan your enrollment forms into our system, making them easier and faster to access. Better quality forms help us to process your enrollments faster. Unfortunately, certain forms are difficult or impossible to scan. The following list of helpful hints will make your forms easier to scan:Do:1) submit clear, legible enrollment forms.2) underline or circle important information.3) use blue or black ink.

Don’t:1) submit dark copies as they appear black on imaging.2) highlight, which blackens the area so it cannot be read.3) write on the top or bottom margins. This information is not always

captured on the image system.

REL 1 Rev. 05-11 Page 2 of 2 09-07-17

Policy and Div. # 136- _____________________________




1 to enroll Dental To terminate all coveragesEmployee InformationMarital Status Single Married Civil Union* Domestic Partner* *As defined by state law or your Group.






E-mail address (limit of 60 characters) ___________________________________________________________________________________

Are you covered under another dental insurance plan? . . . . . . . . . . . . . . . . .Employee: Yes No Dependents: Yes No


Print full legal name (last, first. MI)Dental


student?add drop

1

2

3

4

5

Please Sign (employee/policyholder) The certificate provides dental benefits only. Review your certificate carefully.As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case of a life event. This information was explained in the plan’s solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate to the best of my knowledge. The policyholder certifies the date of employment, job title, hours worked and salary information are correct according to the Policyholder’s records.















because _________________________________________________________________________________________________________


REL 1 Rev. 05-11 Page 1 of 2 Dental 04-14-17





Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al 877-233-3797. Para obtener más ayuda, llame al Departamento de Seguros de CA al 800-927-4357.

Note for Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Note for Florida Residents: 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.

Note for Georgia, Kansas, Nebraska, Oregon, Vermont and Virginia Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

Note for Kentucky Residents: 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.

Note for Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss of 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.

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

Note for New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Note for New Mexico and Rhode Island Residents: 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 civil fines and criminal penalties.

Note for North Carolina Residents: After 2 years from the date of issue or reinstatement of this policy, no misstatements made by the applicant in the application shall be used to void the policy or deny a claim for loss commencing after the expiration of such 2 year period.

Note for Pennsylvania Residents: 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 subjects such person to criminal and civil penalties.

Note for Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of coverage.

Note for Texas Residents: Any person who knowingly and with intent to defraud provides false, incomplete or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, may be guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim.

Note for Washington, D.C. Residents: 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.

Note for Washington Residents: For groups policies issued, amended, delivered, or renewed in Washington, dependent coverage includes individuals who are registered domestic partners and their dependents.







To ChangeChanging Dependent Codes – When adding or dropping dependents, please note whether this change is because of a “life event” or for some other reason. (Examples of life events: marriage, birth of a child, divorce . . . ) Please remember to include the date of the event. Late entrant status will be applied if a life event is not included. Be specific when changing status so all dependents who are still eligible will be covered.




REL 1 Rev. 05-11 Page 2 of 2 Dental 04-14-17

Policy and Div. # 136- _____________________________




1 to enroll Eye Care To terminate all coveragesEmployee InformationMarital Status Single Married Civil Union* Domestic Partner* *As defined by state law or your Group.






E-mail address (limit of 60 characters) ___________________________________________________________________________________

Are you covered under another eye care insurance plan? . . . . . . . . . . . . . . . .Employee: Yes No Dependents: Yes No


Print full legal name (last, first. MI)Eye Care


student?add drop

1

2

3

4

5

Please Sign (employee/policyholder) The certificate provides eye care benefits only. Review your certificate carefully.As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case of a life event. This information was explained in the plan’s solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate to the best of my knowledge. The policyholder certifies the date of employment, job title, hours worked and salary information are correct according to the Policyholder’s records.















because _________________________________________________________________________________________________________


REL 1 Rev. 05-11 Page 1 of 2 Eye Care - High/Low 04-14-17


Select plan High Low




Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al 877-233-3797. Para obtener más ayuda, llame al Departamento de Seguros de CA al 800-927-4357.

Note for Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Note for Florida Residents: 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.

Note for Georgia, Kansas, Nebraska, Oregon, Vermont and Virginia Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

Note for Kentucky Residents: 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.

Note for Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss of 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.

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

Note for New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Note for New Mexico and Rhode Island Residents: 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 civil fines and criminal penalties.

Note for North Carolina Residents: After 2 years from the date of issue or reinstatement of this policy, no misstatements made by the applicant in the application shall be used to void the policy or deny a claim for loss commencing after the expiration of such 2 year period.

Note for Pennsylvania Residents: 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 subjects such person to criminal and civil penalties.

Note for Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of coverage.

Note for Texas Residents: Any person who knowingly and with intent to defraud provides false, incomplete or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, may be guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim.

Note for Washington, D.C. Residents: 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.

Note for Washington Residents: For groups policies issued, amended, delivered, or renewed in Washington, dependent coverage includes individuals who are registered domestic partners and their dependents.







To ChangeChanging Dependent Codes – When adding or dropping dependents, please note whether this change is because of a “life event” or for some other reason. (Examples of life events: marriage, birth of a child, divorce . . . ) Please remember to include the date of the event. Late entrant status will be applied if a life event is not included. Be specific when changing status so all dependents who are still eligible will be covered.




REL 1 Rev. 05-11 Page 2 of 2 Eye Care - High/Low 04-14-17

Electronic Funds Transfer (EFT) Form

Request and Authorization for Bank Payment Plan

It’s the simplest method of paying your premium. No more checks to write! It’s automatic and reliable. We call it electronic funds transfer (EFT for short). It allows for peace of mind however you do business — whether it’s online or through the mail.

Online: Groups that receive invoices online, you have the freedom to choose when we debit your account. When you’re ready, just visit our website, reliancestandard.com/dental-vision, sign into your secure account and click PAY BILL. We’ll draft your premium payment right away.

Mail: Groups that receive their invoices through the mail, just authorize us to debit your account each month and we’ll do the rest. It’s the forget-proof method of paying your premium.

Authorized Agreement for Prearranged Payments (Debits)

Group Policy #______________________________ Phone # ________________________________________

Policyholder Name ___________________________________________________________________________

Policyholder Contact __________________________________________________________________________

l New Authorization l Change of Account

l Checking Account l Savings Account

I hereby authorize Reliance Standard to initiate debit entries to the account number listed below, and at the bank named below, herein called BANK, to debit the same to such account. Draft day will be on or about the day “PAY BILL” is requested by policyholder.

Bank Account Number____________________________Bank Routing Number (9 digits) ___________________

Bank Name _________________________________________________________________________________

Account Name _______________________________________________________________________________

Address ____________________________________________________________________________________

City___________________________________________ State______________________ ZIP ______________

Phone Number of Financial Institution ____________________________________________________________

To ensure a timely and effective setup, it is necessary to send a voided check with this request.

This authorization is to remain in full force and in effect until BANK has received written no ti fi ca tion of its termina-tion in such time and such manner as to afford BANK a reasonable op por tu ni ty to act on it. A customer has the right to have the amount of an erroneous debit im me di ate ly credited to his/her account by BANK up to 15 days following issuance of statement of account or 45 days after the charge, whichever comes first.

Name (Print)_________________________________Title of Authorized Signer ___________________________

Signature ___________________________________________________________________________________

Date_______________________________________ Federal Tax ID# __________________________________

REL 94 Rev. 4-13 Please keep a copy of this form for your records.

P.O. Box 82510 / Lincoln, NE 68501-2510Phone: 800-497-7044 / Fax: 402-467-7338

CLEAR FORM

Reliance Standard Life Insurance Company is licensed in all states (except New York), the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. In New York, insurance products and services are provided through First Reliance Standard Life Insurance Company, Home O ce: New York, NY.

Administration Guide for Reliance Standard Policyholders

Documents

Transcript of Administration Guide for Reliance Standard Policyholders