352-750-5921 FAX NUMBER

PLEASE FAX COMPLETED DOCUMENTS BACK TO
NHPP
352-750-5921 FAX NUMBER
C/O: NHPP / PAN AMERICAN MEDICAL PLAN
NOTE:
YOU WILL NEED TO PRINT OFF THE APPLICATION (A)
SEPARATELY.
ALL THREE (A, B, C) ABOVE PAGES MUST BE
COMPLETED AND SUBMITTED.
YOU DO NOT NEED TO SEND MONEY:
WE WILL DRAFT YOUR FIRST MONTH’S PREMIUM
C & SCT INDEMNITY PLAN/PLAN DE INDEMNIZACION C & SCT
PAN-AMERICAN LIFE INSURANCE COMPANY
Your Last Name/Apellido
GROUP ENROLLMENT FORM/FORMULARIO DE INSCRIPCCION COLECTIVA
First Name/Nombre
Your Address/Dirección
City/Ciudad
Social Security No./No. de Seguro Social
Group Number/Número de Grupo
Employer’s Name/Nombre del Empleador
County/País
Date of Birth/Fecha de Nacimiento
/
/
Home Phone/Teléfono de la Casa
(
¨ Male/Hombre
¨ Female/Mujer
Middle Initial/Segundo Nombre
)
State/Estado
Zip Code/Código Postal
Date of Employment/Fecha de Empleo
/
Do you have an eligible spouse?
¿Tiene in cónyugue que califique?
Address/Dirección
City/Ciudad
County/País
State/Estado
Zip Code/Código Postal
/
¨ Yes/Sí
¨ No/No
¨ Single/Soltero
¨ Divorced/Divorciado
How many eligible children do you have?
¿Cuántos niños elegibles tiene?
Location of Employment/Lugar de Empleo
¨
¨
Married/Casado
¨
Widowed/Viudo
Legally Separated/Separado Legaimente
Plan
List first names and complete for all eligible dependents proposed for insurances/Lleno los nombres y complete para todos los dependientes elegibles propuestos como asegurados:
Spouse/Cónyugue
Date of Birth/Fecha de Nacimiento
Sex/Sexo
Age/Edad
Social Security No./No. de Seguro Social
Children/Niños
Date of Birth/Fecha de Nacimiento
Sex/Sexo
Age/Edad
Social Security No./No. de Seguro Social
Beneficiary/Beneficiario
If they are ages 19-26, are they a full-time college student?/
Si tienen 19 a 26 años, ¿son alumnos de tiempo completo en
a unversidad?
¨ Yes/Sí
¨ No/No
¨ Yes/Sí
¨ No/No
¨ Yes/Sí
¨ No/No
Relationship to you/Relación con Ud.
I hereby declare that I am an active employee of the employer indicated above and that I work at or from the employment location indicated. All information given by me on this form at PanAmerican Life Insurance Company’s request is true and complete and is offered Pan-American Life Insurance Company as inducement to grant insurance.
Por la presente declaro que soy un empleado activo del empleador antes indicado y que trabajo en o del lugar indicado. Toda la información divulgada por mi en este formulario a solicitud
de Pan-American Life Insurance Company es fiel y correcta y se ofrece como incentivo a Pan-American Life Insurance company para que otorgue seguro.
NOTICE CONCERNING YOUR RIGHTS OF PRIVACY AS A CONSUMER
Pan-American Life Insurance Company collects nonpublic information about you from the following sources:
• Information we receive from you in applications or other forms;
• Information about your transactions with us, our affiliates or others; and
• Information we receive from a consumer reporting agency.
We do not disclose any nonpublic information about our customers or former customers to anyone, except as permitted by law.
We restrict access to your nonpublic personal information to those employees who need to know that information to provide products or services to you. We maintain physical, electronic
and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.
¨ I have been given the opportunity to apply for this insurance, but do not desire to participate.
AVISO RESPECTO A SUS DERECHOS DE PRIVACIDAD COMO CONSUMIDOR
Pan-American Life Insurance Company recibe información personal, que no es de naturaleza pública, acerca de sus clientes, proveniente de las siguientes fuentes:
• Información recibida del cliente mismo en la solicitud y otros formularios
• Información acerca de las transacciones del cliente con la Compañía, nuestras afiliadas u otras entidades; e
• Información recibida de agencias que reportan sobre los consumidores.
Pan-American Life Insurance Company a nadie divulga información personal alguna, que no sea pública, respecto a clientes activos o clientes inactivos, excepto como sea permitido por la
ley.
Pan-American Life Insurance Company restringe el acceso a la información personal del cliente, que no sea pública, permitiendo el acceso sólo a los empleados y funcionarios que necesitan
conocer esa información a fin de proveer productos y/o servicios al cliente mismo. La Compañía tiene procedimientos de seguridad manuales, electrónicos y de proceso para cumplir con
los requisitos legales para proteger la información personal, que no sea pública, del cliente.
¨ Se me ha dado la oportunidad de aplicar para este seguro, pero no deseo participar.
Date Signed/Fecha Firmada ______________________________
Form A-3607-FB2 Rev. 4-01
Your Signature /Su Firma ________________________________________________
Enroller/Agent________________________
NHPP 90897
FMG 57-0996575
Ocenture LLC
NHPP 90897
ELECTRONIC FUNDS TRANSFER AUTHORIZATION
REQUEST FOR PRE-AUTHORIZED WITHDRAWAL OR A CHANGE TO AN EXISTING EFT
† Start New Deduction
† Change Routing Number or Account Number
† Add to Existing EFT Account Number _________________________
I hereby authorize Ocenture LLC to make withdrawals from my account for the purpose of paying membership
fees for the below persons:
Depositor Name (First, MI, Last
Financial Institution Name
Mailing Address of Depositor
Financial Institution Address
Telephone Number of Depositor
Telephone Number of Financial Institution
Depositor Account Number
Transit Routing Number (9 digits)
Check One:
† Checking Account – for checking account please attach VOID check.
† Savings Account – for savings account, please ask your financial institution to verify
that this EFT will be accepted and that the above information is correct. This verification is
necessary as not all financial institutions will acknowledge an EFT debit to a savings account.
I herby authorize OCENTURE LLC, to initiate an initial debit entry to my account for the amount listed below. I /
We also authorize OCENTURE LLC to initiate an ongoing debit/credit entry to my account monthly for the
amount listed below. I understand that initial/ongoing fees may include any returned unpaid item fees due, on
which the subject of this agreement is drawn and the financial institution at which the account is held to debit the
same to such account. This authority is to remain in full force and effect until OCENTURE LLC and the subject
Financial Institution have received written notification from me or its termination in such time and in such manner
as to afford OCENTURE LLC and the Financial Institution a reasonable opportunity to act on it. I understand
that I may cancel this authorization by providing written notice to OCENTURE LLC at least seven (7) business
days prior to the payment due date. I further understand that canceling my authorization does not relieve me of
the responsibility of paying my account in full.
Initial Debit Amount (First Month Membership Fee)
$______________
Monthly Recurring Amount (Monthly Membership Fee)
$______________
9______________________________________
Signature
_______________
Date
______________________________________
Printed Name
Ocenture LLC – PO Box 1559 – Ponte Veda Beach – Florida – 32004
904-821-9245 – 253-663-5463 Fax
FORM B
The National Companies, Inc. Representative
Addendum to Pan-American Life Insurance Company
C & SCT Indemnity Plan
It is understood and acknowledged by you by the execution of this Addendum below, that the
use of the term "Employee" to refer to Independent Marketing Representatives in the Application neither
changes nor is it intended to change the status with Order Number: 74851Order Date: 12/31/2002 For all
purposes, including purposes of local, state and federal taxation status and the status of their
association with The National Companies, Inc. Independent Marketing Representatives are and shall
remain Independent Contractors (Independent Representative).
It is understood and acknowledged by you by the execution of this Addendum below, that this
Application does not create nor is it intended to create a contract or any part of a contract of
employment in whole or in part, either expressed or implied, between The National Companies, Inc. and
any Independent Associate submitting and/or completing an Application. Further, it is understood and
acknowledged that no representative of The National Companies, Inc., except the Chief Operating
Officer (COO) or his designee, so authorized in writing, has the authority to enter into any agreement for
employment for any specified period of time or to make any agreement contrary to the at-will
employment arrangement The National Companies, Inc. maintains with its exempt and non/exempt
employees. Any such Agreement is void unless in writing and signed by the COO of The National
Companies, Inc. or his designee.
By my signature below I hereby acknowledge that I have received and read a copy of this
Addendum in its entirety prior to completing the attached Application and that I further understand and
agree to its terms and restrictions.
______________________________________________
Representative's Name
______________________________________________
Representative's Signature
______________________________________________
Date
FORM
C