I hereby represent that to the best of my knowledge and belief, no person to be insured under this policy has received treatment for* or been medically advised of Cancer (excluding Skin Cancer) within the last 5 years (3 years in LA, 2 years in VT, 12 months in TX, 6 months in ID, NV, and UT).
It is understood that no benefits will be payable for expenses incurred during the first 12 months (6 months in ME, UT, and VT) of coverage for any cancer diagnosed or treated within the first 30 days after the insured person’s effective date of coverage.
Upon receipt of your activation form, a Certificate of Insurance be mailed to you. For your convenience, you will be billed monthly.
I and, if indicated, my spouse hereby enroll for Cancer Care coverage as provided by Securian Life Insurance Company. I understand that my insurance coverage will become effective on the Effective Date stated in the Schedule, provided my first payment is paid and received by the Plan Administrator. I understand any cash benefit checks will be payable as outlined above subject to policy provisions. I acknowledge I have received, read, and understand the disclosures below.
*(Treatment means medical and surgical care by a licensed provider to detect or cure Cancer. This includes examination, diagnostic procedures, surgery (including pre- and post-operative care), prescribed medication, and the application of remedies and therapy. It does not include any diagnostic procedures or examinations performed to monitor a previous removal or remedy of Cancer, provided there is no positive diagnosis of Cancer or of a recurrence of Cancer.)
Arkansas:
I understand that this is not a policy that satisfies the Federal requirement for health insurance coverage and is not a substitute for Major Medical Insurance. No person may be covered for specified disease (cancer) if they are covered by any Title XIX program (Medicaid or any similar name). Fraud Warning: 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.
Idaho:
I understand that in order to be eligible for this coverage, I am not covered by any Title XIX program (Medicaid or any similar name).
Louisiana:
THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN ADDITIONAL PAYMENT WITH YOUR TAXES. Fraud Warning: 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.
Maine:
THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN ADDITIONAL PAYMENT WITH YOUR TAXES. No person may be covered for specified disease (cancer) if they are covered by any Title XIX program (Medicaid or any similar name).
Fraud Warning: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Missouri:
I understand the policy applied for will not pay benefits for any loss incurred during the first 12 months of either not receiving care or 24 months after the effective date, whichever occurs first on account of disease or physical condition which I now have or have had in the past.
North Dakota:
By applying for this insurance, do you intend to replace, discontinue or change an existing policy or contract? [ ] Yes [ ] No (Note: the answer to the question needs to be captured, but no processing is needed and application can be accepted regardless of how the question was answered.)
South Carolina:
I understand this coverage contains a pre-existing condition limitation.
Utah:
No person may be covered for specified disease (cancer) if they are covered by any Title XIX program (Medicaid or any similar name).
I understand that the coverage contains a benefit waiting period of 30 days and that any coverage issued is subject to a pre-existing condition limitation of 6 months.
Fraud Warnings:
RI, WV: 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.
CO: 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.
DC: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny benefits if false information materially related to a claim was provided by the applicant.
FL: 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.
KY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact thereto, commits a fraudulent insurance act, which is a crime.
MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
NM: 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.
OH: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PA: 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.
TN: 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.
VA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
