Page 29 - Prestige Brochures & Enrollment Packet

WAIVER

This Page Is Only For People Who Do Not Want To Enroll
In Any Benefits

If You Are Enrolling In 1 Or More Benefits, Skip This Page

If you do not wish to enroll in any of the Allstate Benefits, please

sign the waiver below and return your packet to the Allstate

Benefits Specialist

I acknowledge that I was offered the opportunity to enroll in the following Allstate Benefits
during the initial open enrollment period in December of 2018, and I am waiving my opportunity
to enroll in any of them.

Short-Term Disability Term Life Insurance Universal Life Insurance Dental Insurance

Vision Insurance Accident Insurance Critical Illness/Cancer Insurance

I understand that by waiving participation during this initial open enrollment period, in which
relaxed qualification underwriting (GI* or CGI*) is available, that I will be required to undergo
full underwriting qualification (SI*) should I later decide that I do want to participate.

I understand that this initial enrollment period is the only opportunity I will have to participate
and qualify under the relaxed (GI* or CGI*) qualification underwriting and that I could be denied
coverage in the future if I do not meet the regular underwriting standards (SI*).

_______________________ _______________________ ________________
Print Name Signature Date

SI - Simplified Issue: Requires answers to several medical questions, height/weight, etc.
CGI - Contingent Guaranteed Issue: Only requires the answer to two medical questions and does not consider height /weight.
GI - Guaranteed Issue: Does not have any medical questions.