CRITICAL ILLNESS DISCLOSURE STATEMENT
The following statements must be reviewed carefully and signed as indicated:
Yes, I would like to accept Critical Illness Coverage


No, I would not like to accept Critical Illness Coverage

(I / we) the undersigned, have been shown the critical illness protection offered to us by our USA Benefits Group agent. (I / we) understand that (I / we) are declining the lump sum benefit to be paid to us in the event of a critical illness and that (I/we) will be responsible for our health insurance deductible as well as any out of pocket expenses incurred for time off work due to such an illness.

Further, (I / we) choose to decline the guaranteed renewable life insurance benefit offered as part of this critical illness insurance. (I / we) have had the coverage and benefits explained to us and choose not to participate at this time.
  Primary Applicant's Full Name:  
Re-Enter Primary Applicant's Name:
Secondary Applicant's Full Name:
Re-Enter Secondary Applicant's Name:
*Agent is required to obtain all necessary signatures.