Enrollment Form Optalis

First and last name

Employee SSN:

Employee Street Address

City, State, Zip

Employee Phone Number

Employee Birth Date

Employee Hire Date

Employee Email

Facility Name

Dependent Information (If you are opting for dependent coverage, please complete)

Spouse Name

Child 1 Name

Child 2 Name

Child 3 Name

Child 4 Name

Spouse Birth Date

Child 1 Birth Date

Child 2 Birth Date

Child 3 Birth Date

Child 4 Birth Date

Spouse SSN

Child 1 SSN

Child 2 SSN

Child 3 SSN

Child 4 SSN

UNUM Whole Life (Please refer to the rate sheet for specific coverage amounts)

$6 Bi-Weely Premium

$12 Bi-Weely Premium

$18 Bi-Weely Premium

Please list your life insurance beneficiary

To decline UNUM Whole Life, type DECLINE in the box below:

Aflac - Group Accident Insurance

$6.19 Group Accident Emplooyee Only

$10.57 Group Accident Employee + Spouse

To decline Group Accident Insurance, type DECLINE in the box below:

$14.51 Group Accident Employee + Child(ren)

$18.89 Group Accident Family

Aflac - Group Hospital Insurance

$9.39 Group Hospital Emplooyee Only

$18.89 Group Hospital Employee + Spouse

To decline Group Hospital Insurance, type DECLINE in the box below:

$15.06 Group Hospital Employee + Child(ren)

$24.56 Group Hospital Family

Aflac - Group Critical Illness Insurance

$5000 Employee

$10,000 Employee

$15,000 Employee

$20,000 Employee

$25,000 Employee

$5000 Spouse

$10,000 Spouse

$15,000 Spouse

$20,000 Spouse

$25,000 Spouse

$30,000 Employee

$30,000 Spouse

To decline Critical Illness Insurance, type DECLINE in the box below:

Electronic Signatures. Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Employee Electronic Signature

Date

Please continue to the next section to authorize electronic payments through your financial institution.

Payment Authorization

NAME OF EMPLOYER ORGANIZATION

Employee Name

Type of Insurance

Bi-Weekly Premium Amount

Group Accident

Group Hospital

Employee Critical Illness

Spouse Critical Illness

UNUM Whole Life

SUBTOTAL

Administrative Fee

$2.31

TOTAL DRAFT

Completed by administrator:

Date of 2nd Draft:

Group #: 28033

Select one:

New Application

Change Request

Date of 1st Draft:

BANK INFORMATION - checking account only

I choose to pay by Electronic Bank Draft. (A $25 service charge will be assessed on all returned bank drafts)

Financial Institution

Routing Number

Account Number

Name as it appears on check

Employee Electronic Signature

Date

Click the button below to submit benefit elections and payment authorization.

I hereby request Pioneer Pacific Consultants, Inc. dba PIOPAC Fidelity to draft my payment card or bank account, in the amount shown above or an amount greater of up to 20% in the event carrier product increases rate of premiums at renewal, and to receive notices of premiums due via email, text message, and/or phone call on policies for which I have made application. This authorization shall remain in effect until written notice is provided to PIOPAC Fidelity by me to discontinue them. This authorization is not dependent upon my employment or membership terminate. In consideration of the honoring of my request, I understand and agree to the following conditions: 1) Drafts shall be made as scheduled. 2) Drafts will include the per-cycle administrative fee indicated above. 3) If any charge is not honored on presentation and if any premium is not paid, the policy(ies) may lapse in accordance with its terms and 4) there is a reprocessing fee of $25 assessed on all returned ACH Drafts, $15 for declined credit/debit card monthly withdraw on my draft account and a $25 Non-Negotiable Fee for any/all ACH, Debit/Credit Card Disputed Charges5) PIOPAC Fidelity, Inc. may automatically revoke this Authorization if any charges are not paid on presentation. 6) This Authorization shall not be construed as a modification of any of the provisions of the policy(ies). 7) The Insurer, the Premium Payor or the Bank may cease Authorization by giving 10 days’ written notice to PIOPAC Fidelity. 8) If the Authorization is revoked, premiums falling due thereafter may be payable directly to the insurer. 9) In the event of a dishonored draft, I authorize Pioneer Pacific Consultants, Inc. dba PIOPAC Fidelity to contact me via email, text, telephone, or combination. I hereby authorize PIOPAC Fidelity to initiate debit entries electronically to my account indicated above and I authorize the depository institution named above to debit same to such account. These authorizations remain effective and in full force until PIOPAC Fidelity has received written notification from me of its termination in such time and in such manner to afford PIOPAC Fidelity and the depository/institution a reasonable opportunity to act on it.

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