Get Nea Insurance Operations Non Smoker Form

NEA Life/AD D INSURANCE PLANS NON-SMOKER DECLARATION If you wish to request non-smoker rates for yourself or your spouse for the plan indicated below please complete this form and either return it to the address listed below or fax it to 515-365-1520 NEA Insurance Operations P. O. Box 9389 Des Moines IA 50306-9389 Please refer to your last premium notice or your Schedule of Benefits for your certificate number. All changes will be effective the first of the month following the receipt of your request. Please print all information in blue or black ink Certificate Number 8 0 2 - Plan Name Member s Name FIRST MI LAST Spouse s Name if insured Address City State Zip Daytime Phone Number - - Smoking Status During the past 24 months have you used tobacco or nicotine in any form Member Yes No Spouse Spouse must sign below in order to request the non-smoker rate. By signing below I declare the information provided is true and complete. We cannot process your request without your signature. O. Box 9389 Des Moines IA 50306-9389 Please refer to your last premium notice or your Schedule of Benefits for your certificate number. All changes will be effective the first of the month following the receipt of your request. Please print all information in blue or black ink Certificate Number 8 0 2 - Plan Name Member s Name FIRST MI LAST Spouse s Name if insured Address City State Zip Daytime Phone Number - - Smoking Status During the past 24 months have you used tobacco or nicotine in any form Member Yes No Spouse Spouse must sign below in order to request the non-smoker rate. All changes will be effective the first of the month following the receipt of your request. Please print all information in blue or black ink Certificate Number 8 0 2 - Plan Name Member s Name FIRST MI LAST Spouse s Name if insured Address City State Zip Daytime Phone Number - - Smoking Status During the past 24 months have you used tobacco or nicotine in any form Member Yes No Spouse Spouse must sign below in order to request the non-smoker rate. By signing below I declare the information provided is true and complete. We cannot process your request without your signature. O. Box 9389 Des Moines IA 50306-9389 Please refer to your last premium notice or your Schedule of Benefits for your certificate number. All changes will be effective the first of the month following the receipt of your request. Please print all information in blue or black ink Certificate Number 8 0 2 - Plan Name Member s Name FIRST MI LAST Spouse s Name if insured Address City State Zip Daytime Phone Number - - Smoking Status During the past 24 months have you used tobacco or nicotine in any form Member Yes No Spouse Spouse must sign below in order to request the non-smoker rate. By signing below I declare the information provided is true and complete. We cannot process your request without your signature.