To make a change to your Nationwide Health Plan, please ...



To make a change to your Nationwide Health Certificate, please complete the appropriate section that applies to the change(s) you are requesting

Certificateholder’s Name (Please Print):________________________________________ Certificate No. _____________________

( Address Change ( Residence Address ( Billing Address ( Both

Address:__________________________________________________________________________________________

City:______________________________________________ State:_______________ Zip Code:__________________

Phone Number (if applicable): ( ) ______________ - ________________________ *Note: Relocation may affect your premium rate

( Marital Status ( Single ( Married Date of marriage or divorce:___________/__________/_____________

(IF DIVORCE, BOTH INSURED & SPOUSE MUST SIGN FORM) MONTH DAY YEAR

( Change In Payment Mode (INDICATE MONTH EFFECTIVE WHERE APPLICABLE):

Payment Mode Payment Frequency Month Effective

( Direct Mail Bill ($5.00 monthly fee will be added) ( Monthly ( Quarterly ( Semi-Annual ____________

( Annual

( ELECTRONIC FUNDS TRANSFER (EFT) ( Monthly ______________

( Repetitive Credit Card ( Monthly ______________

Complete the following if you choose EFT as your payment mode:

First and Last Name Printed:______________________________________________________________________

Bank Name:____________________________________________ Account Number:_________________________

Routing Number:________________________________________ ( Checking Account ( Savings Account

Note: Please enclose a voided check along with this form

( Change of Beneficiary Subject to the terms of the certificate. I hereby request that the Beneficiary on my Life Insurance be changed to the following,

in lieu of any prior beneficiary designations applicable thereof, which are hereby revoked.

Primary Beneficiary: (To receive proceeds if living at my death)___________________________________________________________

Relationship To Me: ____________________________________________________________________________________

Contingent Beneficiary: (To receive proceeds if living at my death if PRIMARY BENEFICIARY is not then living)____________________

_______________________________________________________________________________________________________________

Relationship To Me:_____________________________________________________________________________________

IMPORTANT: Requested change(s) will not be processed without certificateholder’s signature

Certificateholder’s Signature____________________________________________________________ Date_________________

OR PARENT/LEGAL GUARDIAN OF CERTIFCATEHOLDER IF UNDER 18 YEARS OF AGE

Spouse’s Signature___________________________________________________________________ Date_________________

AND/OR DEPENDENT IF AGE 18 OR OVER

Witness Signature________________________________________ Date__________________________________

( Name Change From:____________________________ To:______________________________________

(Please provide proof of name change when submitting the request)

( Add Newborn/Adopted Child (WITHIN 31 DAYS OF BIRTH OR ADOPTION)

First and Last Name:_____________________________________________________ Date of Birth:________________

Relationship To Insured:__________________________________________________ ( MALE ( FEMALE

Reason for Addition: ( Birth ( Adoption ( Other:________________________

Note: To add a dependent(s) to your certificate (except for a newborn added within 31 days of birth) a completed application is needed and must be underwritten. If approved, coverage will be effective on the first of the month following underwriting approval. Please contact your agent or call 1-xxx-xxx-xxxx for customer service assistance.

( Plan Change (CONTACT YOUR AGENT TO VERIFY IF THIS FORM IS APPROPRIATE FOR THE CHANGE REQUESTED)

Change Plan: ( From Plan________________________________ to Plan________________________________

(This form cannot be used to increase coverage)

( From Medicare Supplement Plan ______________ to Medicare Supplement Plan______________

(This form cannot be used to increase coverage)

( Other:_________________________________________________________________________________

Increase Deductible (only increase allowed on this form): ( From $_______________ to $__________________

Note: If you are interested in any other type of increase of benefits, an application and underwriting will be required. If approved, coverage will be effective on the first if the month following underwriting approval. Please contact your agent or call 1-800-299-6080 for customer service assistance.

( Remove Dependent(s) from Certificate (termination date will be the last day of the month premiums are fully paid through)

First and Last Name:____________________________ Date of Birth:___________________ Relationship:_________

First and Last Name:____________________________ Date of Birth:___________________ Relationship:_________

( Cancel All Coverage Effective Date of Cancellation:______________/____01_________/_____________

Month Day Year

IMPORTANT: Requested change(s) will not be processed without certificateholder’s signature

Certificateholder’s Signature____________________________________________________________ Date_________________

OR PARENT/LEGAL GUARDIAN OF CERTIFCATEHOLDER IF UNDER 18 YEARS OF AGE

Spouse’s Signature___________________________________________________________________ Date_________________

AND/OR DEPENDENT IF AGE 18 OR OVER

Agent’s Signature________________________________________ Agent #_______________________________

Agent phone #___________________________________________ Date__________________________________

Fax Form To 1-877-247-8955 or

Mail Form To: Nationwide health Plans, PO Box 31040, Tampa, FL 33631

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