Medical Insurance Disclosure

Applicant Certification & Attestation

By signing this Application I understand and agree that:

• I hereby request coverage and understand that if the coverage applied for becomes effective, I agree to all terms of the policy to be issued by the Carrier.

• I understand that the producer, if applicable, who solicited this application was acting as an independent contractor and not as an agent of the Carrier. I further acknowledge that the person who solicited this application and upon whose explanation of benefits, limitations or exclusions I relied, was retained by me as my agent, and that such person has no right to bind or approve coverage or alter any of the terms or conditions of the policy.

• I understand that my application is subject to acceptance by the Carrier or its authorized administrator.

• I understand that I have 10 days to review my coverage and request cancellation of this coverage. I will receive a refund of my premiums only. Any administrative, enrollment, or processing fees will not be refunded.

• I have read or have read to me the completed application and understand all statements and agree and certify that to the best of my knowledge and belief, they are true, complete and correctly recorded.

• I acknowledge by signing below that I have received an outline of coverage.

If application is being made for the Hospital Surgical/Physician Office Benefit Rider, the following attestation must be completed: I hereby attest that I am currently enrolled in a Comprehensive Major Medical Health Plan or have other health insurance coverage that provides Minimum Essential Coverage as mandated under the Affordable Care Act (ACA) of 2010.

Fraud Warning: 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.

Signature Disclaimer

You agree and consent the use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using this website; or in accessing or making any transactions regarding this application constitutes your signature, acceptance, and agreement as if actually signed by you in writing. Further, you agree no certification authority or other third party verification is necessary to the validity of your electronic signature; and the lack of such certification or third party verification will not in any way affect the enforceability of your signature or the resulting contract. You warrant that all the information you have provided is true, complete and accurate.

Please note:

• Any electronic document bearing a user’s e-signature will be considered “in writing” and “wet-signed”.

• Any user e-signed document shall be deemed to be an “original” document when printed and used in the normal course of business.

• Absent manifest error, the admissibility, validity, or use of any e-signed electronic document cannot be contested.


I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify The Loomis Company or its designated administrator in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that The Loomis Company or its designated administrator may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form. If applicable, premium will be debited immediately following receipt of the form.


Additional Terms

This package is not qualified health insurance under the Affordable Care Act (ACA or Obamacare). This package will not provide ACA minimum essential coverage (benefits such as mental healthcare, pregnancy and childbirth, preventive care, etc.), will not help avoid the ACA tax penalty (the individual shared responsibility payment, does not qualify for government subsidies (advanced premium tax credits or cost-sharing reductions), and may not cover pre-existing conditions (health and other conditions that exist before a policy begins).

I have read the documentation for each product in this package so I understand the coverage limitations, exclusions, deductibles, and other terms of each product. I understand the products in this package each have their own terms. If I buy a policy timed to go into effect after another policy ends, I understand that when the new policy goes into effect it does not count any amount I spent towards the deductible or other policy requirements under the old policy and the new policy may make a new determination of whether I have a pre-existing condition that may limit or exclude coverage.