PIA Trust Products and Services - Hospital Indemnity Insurance Individual Census Form


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Hospital Indemnity Insurance

Individual Census Form
This is not an application for insurance. Please submit a separate census form for each person requesting a proposal.
Name
Gender	Male Female
Agency Name
Address
City		State	Zip Code
Phone Number
Fax Number
Number of hours worked per week
Date of Birth
Coverage is being requested on:	Member/Employee Member/Employee & Spouse Member/Employee & Child Member/Employee & Family
If dependent coverage is being requested: (Only available if Member/Employee has coverage)
Spouse's Name
Date of Birth
Dependent 1 Child's Name
Date of Birth
Dependent 2 Child's Name
Date of Birth
Dependent 3 Child's Name
Date of Birth
Dependent 4 Child's Name
Date of Birth
Benefit Amount: ($50, $100, $150, or $200 daily): Spouse's benefit amount cannot exceed Member's/Employee's benefit amount. Children's benefit amount cannot exceed 50% of Member's/Employee's benefit amount.
Member/Employee:
Spouse:
Children:
Optional At Home Recovery Lump Sum:	Member/Employee Member/Employee & Spouse Member/Employee & Family $1000 $2000

If dependent coverage is being requested: (Only available if Member/Employee has coverage)