HOW DO I ENROLL?

To participate, simply fill out the enrollment form below and return it to KACO. Your coverage will begin on the first day of the following month that you become eligible.  If you decline coverage, or intentionally remove yourself from this plan at a later date, you will not be able to re-enroll until the anniversary date of your KACO’s policy.

Although we know you will find the enclosed supplemental benefits program to be extremely valuable, please understand that it is not a substitute for a catastrophic major medical health plan.  Also, it will be important for you to understand that these benefits pay in addition to any other benefits you may have!

NOTICE CONCERNING YOUR RIGHTS OF PRIVACY AS A CONSUMER

Pan-American Life Insurance Company collects nonpublic information about you from your application, other forms, your transactions with us or our affiliates and consumer reporting agencies.  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 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.

›  Plan One

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PAN-AMERICAN LIFE INSURANCE COMPANY                                                      GROUP ENROLLMENT FORM

Your last Name         First Name     Middle Initial						Male     › Female  ›		Social Security #		Date of Birth     /      /	Date of Employment     /       /
Your Address						KENYA ASSOCIATION OF CENTRAL OHIO				Group Number:
Number and Street						Address
City                County             State           Zip Code						City                     County               State                        Zip Code
Home Phone (    )	Do you have an eligible Spouse?			How many eligible children do you have?						› Single       › Married › Divorced  › Legally Separate › Widowed
Location of Employment						› No coverage selected
List First names and complete for eligible dependents proposed for insurance:
Spouse		Date of Birth	Sex		Age		Social Security #
Children		Date of Birth	Sex		Age		Social Security #		If they are ages 19-26, are they a full-time college student? › Yes                    › No
									› Yes                    › No
									› Yes                    › No
Beneficiary                                                                                                           Relationship to you

I hereby declare that I am an active Member of KACO. All information given on this form at Pan-American Life Insurance Company’s request is true and complete and is offered to Pan-American Life Insurance Company as inducement to grant insurance.

Date Signed ___________________________________                     Your Signature____________________________________

Security Question – Mother’s Maiden Name: ____________________________________