Application for Group Supplemental Medical Reimbursement Insurance - Pan-American Life Insurance Company

If you have any questions during the application process, please call us at 866-797-3343.

1Group Information > 2Eligibility > 3Review Your Entry > 4Payment
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Administered by: BeniComp Group, 8310 Clinton Park Drive, Fort Wayne, IN 46825
State
Name of Group Applying
Maximum of 60 characters allowed. Currently Entered: 0 characters.
Federal ID #
Must be between 9 and 10 digits. Currently Entered: 0 digits.
Group Address Group Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Group Phone Number Group Phone Number - ### - ### ####
Effective Date of Insurance Effective Date of Insurance / MM / DD YYYY

Effective dates are the first of the month.
Nature of Business
Nature of Business
If Other Please Specify
Type of Business
Other:
Name of Employee Contact Name of Employee Contact First Last
Employee Contact Title
Employee Contact Email
Employee Contact Phone Number Employee Contact Phone Number - ### - ### ####
"> Pulse ID
Names and Locations of any subsidiaries or affiliates to be insured:
Do you have an agent?

Do you have an agent? Yes No
I certify that I have truly and accurately recorded on this application the information supplied by the Applicant.
Agent Name Agent Name First Last
Agent's State License Number
Agent's Phone Number Agent's Phone Number - ### - ### ####
Agent's Email Address
Name of Firm
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Taxpayer I.D. Number
Agent Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
BCS-A-07 11/2007
BCS-A-07-AR 11/2007
BCS-A-07-CA 11/2007
BCS-A-07-FL 11/2007
BCS-A-07-ID 11/2007
BCS-A-07-KY 11/2007
BCS-A-07-LA 11/2007
BCS-A-07-MN 11/2007
BCS-A-07-NC 11/2007
BCS-A-07-ND 11/2009
BCS-A-07-OK 11/2007
BCS-A-07-OR 11/2007
BCS-A-07-TN 11/2007
BCS-A-07-VA 11/2007
BCS-A-18-GA
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Application for Group Supplemental Medical Reimbursement Insurance - Pan-American Life Insurance Company

Application for Group Supplemental Medical Reimbursement Insurance - Pan-American Life Insurance Company

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Application for Group Supplemental Medical Reimbursement Insurance - Pan-American Life Insurance Company

Application for Group Supplemental Medical Reimbursement Insurance - Pan-American Life Insurance Company

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