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as marriage, divorce, or termination of employment of spouse) as allowed by Internal Revenue Service (IRS) regulations and
my employer’s plan.
I understand that my selection of coverage and indication that premium is to be paid does not necessarily guarantee coverage.
In most instances, I must also complete an application. The effective date will be as set forth in my policy or confirmation of
coverage.
I have read and understand the enrollment materials provided, including disclosures regarding exclusions, limitations, offsets
and any outlines of coverage.
I have read, agree with, and confirm the accuracy of the above information.
I have read and agree to all terms listed above.
Signature: _ Electronic Signature on File for Samantha Hanson _ Date: _6/30/2020 5:22:27 PM EDT_
Aaron Wichmann | 769618
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
https://harmonyenroll.coloniallife.com/V13/Core.Web/elections/BatchElectionForm.aspx?A... 7/8/2020
