(Insurer's name and address) |
IMPORTANT INFORMATION ABOUT THE COVERAGE YOU ARE BEING OFFERED |
Save this statement! It may be important to you in the future. The Washington State Insurance Commissioner requires that we give you the following information about the coverage offered to you under a group policy issued by (insurer) , (to/on behalf of) (association or organization) .
The policy is subject to and governed by the laws of the state of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
The certificate of coverage issued to you is governed by the state of Washington.
The Washington State Insurance Commissioner has authority to assist you concerning your coverage.
To keep this coverage, you (must/need not) continue membership in the group. If you are not now a member, the initial cost of membership is $. . . . Additional dues or membership fees are currently $. . . . per . . . . Membership costs (may/will not) increase in future years. You will also have the premiums to pay.
The coverage (can/can not) be discontinued by the group. It (can/can not) be terminated by the insurer. If the group organization ceases to exist, your coverage (would/would not) terminate. You (are/are not) entitled by the contract to convert your coverage to your own policy.
(Group organization's name) (will/will not) be paid for its participation in this insurance program. (An explanation of payments must be inserted here.) .
If you apply for this coverage, you (will/will not) have a "free look" (of . . . . days*) during which you may cancel your contract and recover your premium without obligation. Your membership fee to join the group (is/is not) refundable. *(Omit phrase, "of . . . . days", if there is no "free look.")
DELIVERED to the applicant this . . . . . . . day of (month) , (year) , by
(Signed) . . . . . . . . . . . . . . . . . . (insurance producer).
Printed Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
I ACKNOWLEDGE THAT I HAVE RECEIVED AND UNDERSTAND THIS DISCLOSURE STATEMENT: . . . . . Applicant.
Wash. Admin. Code § 284-30-610
Statutory Authority: RCW 48.02.060(3)(a) and 48.17.010(5). 11-01-159 (Matter No. R 2010-09), § 284-30-610, filed 12/22/10, effective 1/22/11. Statutory Authority: RCW 48.02.060, 48.30.010, 48.01.020, 48.01.060. 00-19-048 (Matter R 98-18), § 284-30-610, filed 9/14/00, effective 10/15/00. Statutory Authority: RCW 48.02.060(3)(a) and 48.30.010. 91-03-073 (Order 90-14), § 284-30-610, filed 1/16/91, effective 4/1/91.