AD&D Enrollment Form
FOR MEMBERS OF
Professional Association of Georgia Educators
Underwritten by ReliaStar Life Insurance Company
Use this application to apply for Accidental Death & Dismemberment Insurance (AD&D). Please fill out the form below. Plan administred by: NEBCO, 8500 Freeport Parkway South, Suite 450, Irving, TX 75063. Telephone 800-759-0101; Fax 469-417-1675 or 1676.
Tell us about yourself Policy 68023-1
Member Name: Date of Birth (mm/dd/yyyy):
Address:
City: State: Zip:
Daytime Phone: Other Phone:
Indicate coverage desired: 1) Write in Member coverage desired, and 2) Select plan type
Amount of AD&D Insurance elected: Plan Type:
Indicate the amount of Member coverage applied for on this Enrollment form. You may choose coverage from $100,000 to $300,000, in increments of $5,000.

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Beneficiary information
List one or more beneficiaries below. List the percent each will receive. The total must equal 100 percent. Beneficiary for dependent coverage will be the certificate holder.
Name Address Relationship Percent
 
Read this information carefully, then type your name in the box below.
To the best of my knowledge and belief, the information I’ve provided is complete and correct.
I understand and agree that no coverage shall take effect unless the first premium is paid in my lifetime.
I understand my coverage begins on the “effective date” assigned by ReliaStar Life Insurance Company.

 Any person who knowingly and with intent to defraud, submits an application or files a claim containing any materially false or misleading information, commits a fraudulent act, which is a crime.
Your Signature: Date:
Security:
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July 2013