Requirements of Sold Business

• Original completed Employer Application (46KB PDF)
• Original completed Employee Enrollment Forms (51KB PDF)
• Most current wage and tax statement
• Most current monthly premium statement of the medical insurance carrier
• A copy of the employer’s policy or SPD for medical coverage, showing the waiting period and the number of working hours required to be a full-time, covered individual
• Binder check with first month’s premium
• Copy of the proposal presented

All Originals Must be Sent to the Underwriting Department at SecureScript.

Do not cancel current coverage until a written verification letter has been received confirming the rates, plan design and effective date.

Underwritten by Fidelity Security Life Insurance Company, Kansas City, MO