NATIONWIDE INSURANCE COMPANIES
|NATIONWIDE INSURANCE COMPANIES |DATE ATTAINED CAREER STATUS|
|INDEPENDENT CONTRACTOR AGENT INSURANCE ENROLLMENT FORM | |
|COMPLETE IN FULL (not valid without signature & date) | | | |
| |DATE OF BIRTH |
| | | | | | |
|LAST NAME FIRST NAME MI ST# AGENT # |MARITAL STATUS |
|AGENT MEDICAL – CCN PPO |MEDICARE COMPLEMENT |SINGLE |( |
|((CHECK ONE) |((CHECK ONE) |MARRIED |( |
| |REJECT all Medical | | | | |Medicare Self Spouse | |DIVORCED |( |
| |$2000 deductible 80/70 | | | | |$ 250 With drug | | | |
| | | | | | | | | |SEX |
| |$5000 deductible 100/70 | | | | | | | | |
| | | | | | | |CHILDREN |Y |N |
| | | | | | | | | |
| | |Apply |Reject | | | | | |
| |SPOUSE MEDICAL | | | | |
| |CHILD MEDICAL | | | | |
| |SPOUSE+CHILD MEDICAL | | | | |
| | |
| | |
| |AGENT LIFE COV. | | | |APPLY |REJECT | |
| |((CHECK ONE) | | |DEPENDENT LIFE | | | |
| |PLAN A | | | |STD BENEFIT | | | |
| |PLAN B | | | |LONG TERM DISB. | | | |
| | |
|DEPENDENT INFORMATION |
|DEPENDENT NAME |RELATIONSHIP |DATE OF BIRTH |SOCIAL SECURITY # |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|GROUP LIFE BENEFICIARY |
|PRIMARY |CONTINGENT |
|FULL NAME |RELATIONSHIP |FULL NAME |RELATIONSHIP |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|APPLICATION FOR GROUP ACCIDENT INSURANCE (HIGH LIMIT ACCIDENT) |
|24 Hour Accidental Death and Dismemberment Coverage | |
|( Reject |Principal Sum (Units of $1,000 only) |
|( Agent |$ ,000 | |
|( Spouse |$ ,000 | |
|( All Children (monthly premium is $.36 regardless of number) |$ ,000 | |
|( Pilot Coverage (subject to acceptable Special Aviation Data Sheet) |$ ,000 | |
| PRINT FULL NAME OF AGENT’S BENEFICIARY BELOW (EXAMPLE: JANE DOE, WIFE not MRS. JOHN DOE) |
| |
| (Last) (First) (MI) (Relationship to Agent) |
|OHIO REQUIRED STATEMENT – ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD |
|AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY |
|OF INSURANCE FRAUD. |
|I hereby apply for the Group Insurance for which I am or may become eligible under the Group Policies issued to the Policyholder by the Nationwide |
|Life Insurance |
|Company and/or the Nationwide Mutual Insurance Company, Columbus, Ohio, and authorize the Policyholder to deduct from my commissions, my contribution |
|to the cost |
|of the Group insurance. This authorization shall continue until revoked by the Policyholder. This application cancels and replaces all earlier |
|applications. |
| |
|Signature of Agent | |Date: | | |
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