ADA TERM LIFE PLAN

ADA Identification No. 9 digits required

First Name

Last Name

Address

City

State

Zip

Are you an ADA member?
You must be an ADA Or ASDA Member to apply for this insurance.

Yes No

You must be under age 65 to apply for this insurance.

Are you under age 65?

Yes No

Home Phone

Office Phone

Cell Phone

Fax Number

Email

valid email required

Best way to be contacted (if needed):

Best time to be contacted:

PROMOTIONAL CODE

California Disclosure: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Pennsylvania Disclosure: 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. New York Disclosure: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for such violation. Domestic Partner Disclosure: Definitions, eligibility, and issues arising from any required documentation regarding Domestic Partner coverage are governed by the laws of the state of Illinois.

Copyright © 2009 Great-West Life & Annuity Insurance Company. Benefits for the Term Life Plan are provided under Policy No. 104TLP issued to the American Dental Association and underwritten and administered by Great-West Life & Annuity Insurance Company. Benefits are provided through a group policy filed in the state of Illinois, and all eligible ADA members residing in any U.S. state or territory may apply for coverage. This Policy is subject to, governed by, and shall be construed in accordance with Illinois law. Each approved Plan participant will receive a Certificate of Insurance explaining the terms and conditions of this Policy.