ACCIDENT INSURANCE APPLICATION FORM Insurance Company of North America
Please provide the $1,000 Basic Coverage described in the Summary of Insurance Provisions. I understand there is NO COST to me; the credit union pays the premium.Please print neatly:________________________________________________________
Credit Union Name________________________________________________________
City____________________________ State_____________ Zip___________________
Beneficiary_______________________________________________________________
Member Share Account No. (for identification purposes) __________________________
Member Name____________________________________________________________
Address__________________________________________________________________
Relationship______________________________________________________________
City____________________________ State_____________ Zip___________________
Signature________________________________ Date____________________________
Must be 18 or over to enroll. xx-30026, xx-~2O71, xx-28671a OX 1.0 (Rev. 2/95)
APPLICATION FORM INSTRUCTIONS
You must complete your application form and mail it back to receive your Certificate of Insurance that will be provided at NO COST TO YOU. Simply follow these instructions...
1. Read the attached summary for the details on the protection being provided.
2. Print, Complete and SIGN your application form. IMPORTANT: Your completed form must be on file for you to receive your Certificate of Insurance for the $1,000 of coverage provided at NO COST TO YOU.
3. Mail form to Credit Union, Accident Insurance Administrator, P.O. Box 2429, Redwood City, CA, 94064-2429. Your Certificate of Insurance cannot be issued UNTIL YOUR APPLICATION FORM IS ON FILE.
Your Certificate of Insurance will be mailed to you approximately 30 days after your effective date.
For more information please call TOLL-FREE 1-800-252-2148 weekdays and ask for the "Insurance Desk".