CRITICAL ILLNESS AND/OR ACCIDENT APPLICATION
ReliaStar Life Insurance Company
a member of the Voya® family of companies
Plan Information
Group Policyholder Name: Air Line Pilots Association, International Pilot Welfare Benefit Plan
Group Number: 68920-3
Enrollment Type
Open enrollment
New hire or late entrant with life event change
Type of life event ___________________________________________________________
Date of life event _______ /________ /________
If new hire, please provide hire date _______ /________ /________
Member Information
ALPA member number: ______________________ Airline: ______________________
Is the member actively at work? Yes No
Name (first, middle initial, last):
____________________________________________________________________________________
Gender: Male Female
Date of birth: _______ /________ /________
Street: ____________________________________________________________________________
City: ____________________________ State: ________________ Zip: ____________________
E-mail address: _________________________________________________________________
Residence or cell phone number: (_______) __________ - _____________________
Critical Illness Coverage Requested
Member: $5,000 $10,000 $15,000
$20,000 $25,000 $30,000
Apprentice member:
$5,000 $10,000 $15,000 $20,000
Note: Apprentice members can purchase up to $20,000 for total benefits of $30,000
Spouse critical illness rider:
$5,000 $10,000 $15,000
Child(ren) critical illness rider:
$1,000 $2,500 $5,000 $10,000
Note: Member coverage is required for spouse and/or child(ren) riders
Accident Coverage Requested (choose one option below)
Member
Member and spouse
Member and child(ren)
Member and family
Spouse and/or Child(ren) Information (Complete only if applying for their coverage)
Spouse name: ___________________________________________________________________ Child name: ____________________________________________________________________
Date of birth: _______ /________ /________ Gender: Male Female Date of birth: _______ /________ /________ Gender: Male Female
Child name: ____________________________________________________________________
Date of birth: _______ /________ /________ Gender: Male Female
Acknowledgments and Authorizations
Insurance benefits are contingent on proof of loss. Benefits may require
medical information from your health-care provider.
It is understood and agreed that this application shall be made a part
of the coverage applied for and that no insurance shall be in effect until
approved by the company at its home office, regardless of when the first
premium is paid.
To the best of my knowledge and belief the information on this form is
correct. I understand that false or inaccurate information may result in
the termination of coverage or the nonpayment of benefits.
Signature: _________________________________________________________________ Child name: ____________________________________________________________________
Date of birth: _______ /________ /________ Gender: Male Female
I understand that my coverage begins on the effective date assigned by
ReliaStar Life Insurance Company, provided I am actively at work.
This application is part of the Policy and subject to the terms and
conditions of the Policy. I understand that no agent, representative, or
employee of ReliaStar Life Insurance Company, my employer or any
other entity may change or waive the requirements of this application, or
the terms of the Policy, the certificate, or any riders, except as specifically
set forth in the Policy.
If premium contributions are paid other than annually, finance
charges of 1% per month on the unpaid balance will apply.
Date: _______ /________ /________
Mail to: ALPA Member Insurance, P.O. Box 1169, Herndon, VA 20172-9831 | Fax to: 703-464-2125 | E-Mail to: Insurance@alpa.org