Group Term Life Application

Group Term Life Application for Insurance

Download and print the application, fill in the requested information, sign it, date it, and mail it to:

MEA Financial Services, Inc.
Attn: Group Term Life
P.O. Box 2501
East Lansing, MI 48826-2501

Please note - you can not email this form as it requires a signature

Download the MEA Sponsored Group Term Life Application

Notice Regarding the Medical Information Bureau

Retain this information

One of the prime objectives of the Union Security Company is to provide insurance at low cost on an equitable basis to all policyholders. The underwriting process (evaluation of risks)is necessary not only to assure this low cost, but also to assure that each policyholder contributes his/her fair share of the cost. In considering applications for insurance, information from various sources must, therefore, be considered. These include the results of the proposed insured's physical examination, if required, and any reports we may receive from doctors and hospitals who have attended him/her.

Information regarding factors affecting insurability will be treated as confidential. We may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If application is made to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such company with any information it may have in its file.

Upon receipt of a request, the Bureau will arrange disclosure of any information it may have in the file of the person making the request. (Medical information will be disclosed only to the attending physician of such a person.) If the accuracy of information in the Bureau's file is questioned, the Bureau may be requested to make a correction by following the same procedures as those set forth in the federal Fair Credit Reporting Act. The address of the Bureau's information office is Post Office Box 105, Essex Station, Boston, Massachusetts 02112, telephone number (617) 426-3660.

We may also release information in our file to other insurance companies to whom application is made for life or health insurance, or to whom a claim benefits is submitted.

The purpose of the Bureau is to protect the policyholders of its members from bearing the extra mortality cost created by those who would conceal facts relevant to their insurability. Information furnished by the Bureau may alert the insured to the possible need for further investigation, but under Bureau rules this information cannot be used as the basis for evaluating risks. The Bureau is not a repository of medical reports from hospitals and physicians, and information in the Bureau files does not reveal whether applications for insurance are accepted, rated or declined.

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