Group Executive Insurance Marketing, Inc.
Enrollment Form

Date:
Applying For:
Employers Name:
Employee:
Sex:
Date of Birth:
Marital Status:
Address:
Address2:
City:
State:
Zip:
Social Security Number:
Occupation:
Start Date
Beneficiary Name:
Relationship:
Beneficiary Address:
Do you want coverage for your Eligible Dependents?:
Spouse Name:
Spouse Sex:
Spouse Relation:
Spouse Date of Birth:
1st Child's Name:
1st Child's Sex:
1st Child's Relation:
1st Child's Date of Birth:
1st Child's School:
1st Child's Hours:
2nd Child's Name:
2nd Child's Sex:
2nd Child's Relation:
2nd Child's Date of Birth:
2nd Child's School:
2nd Child's Hours:
3rd Child's Name:
3rd Child's Sex:
3rd Child's Relation:
3rd Child's Date of Birth:
3rd Child's School:
3rd Child's Hours:
4th Child's Name:
4th Child's Sex:
4th Child's Relation:
4th Child's Date of Birth:
4th Child's School:
4th Child's Hours:
5th Child's Name:
5th Child's Sex:
5th Child's Relation:
5th Child's Date of Birth:
5th Child's School:
5th Child's Hours:
Do you or any of your Dependents Smoke?:
Are you or any of your Dependents Pregnant?:
I have Read and Agree to the Subrogation Clause:
 

Subrogation Clause

I declare that all statements in this enrollment form are complete and true and I understand that they are the basis on which coverage may be issued under the plan. I understand that coverage is subject to underwriting acceptance, and if accepted, will not be effective until the first of the month following underwriting approval.

As a condition to participation in and receiving benefits under this plan, covered persons and their dependents agree:
  • To reimburse the plan for any such benefits paid, to or on their behalf, when said benefits are recovered, in any form, from any person, corporation, entity, no fault coverage, uninsured motorist coverage, underinsured motorist coverage, other insurance policies or fund and;
  • Without limiting the preceding, to subrogate the Plan to any and all claims, causes of action or rights that they have or that may arise against any person, corporation and/or other entity who has or may have caused, contributed to, or aggravated the injury or condition for which the covered person(s) and/or their dependent claims an entitlement to benefits under this plan, and to any claims, causes of action or rights they may have against other fault coverage, uninsured motorist coverage, underinsured motorist coverage, other insurance policies or funds ("Coverage").
In the event a covered person or dependant settles, recovers or is reimbursed by any third party or Coverage, the covered person or dependent agrees to hold any such funds received in trust for the benefits of the Plan, and to reimburse the Plan for all benefits paid or that will be paid as a result of said injury condition. The covered person and dependent(s) agree that they will make a decision on pursuing any and all third parties and Coverage within thirty (30) days of the date of the accident or occurrence which led to the injury or condition for which plan benefits are sought, and within said thirty day period will so notify the Plan in writing. In the event the covered person or dependent decides not to pursue any and all third parties of Coverage, or fails to notify the Plan within thirty (30) days of said accident or occurrence of it's intent to do so, the covered person and any dependents authorize the plan to pursue, sue, compromise or settle any such claims in their name, to execute any and all documents necessary to pursue said claims, and agrees to fully cooperate with the Plan in the prosecution of any such claims. The Plan will not pay or be responsible, without it's written consent, for any fees or costs associated with a covered person or dependent pursing a claim against any third party or coverage.