Membership Option (Required)

Death Benefit During Waiting Period

Beneficiary Information

Please designate the beneficiaries for your Life benefit. Percentage % designations must total 100%

Beneficiary 1

Beneficiary 2

Director Level

Payment Information

Disclaimers and Signature

I understand that I am joining the Consumer Benefits of America (CBA) association and I am enrolling into the Membership selection above.I understand that my membership includes access to non-insurance benefits. I understand that my CBA membership includes a Group Term Life Insurance benefit by Guarantee Trust Life Insurance Company, Glenview, IL. I agree to the Death Benefit included in my selected Membership level.

Please see certificate for your plan exclusions. Varies by state.

Group Term Life Insurance is issued on Form Series GLC-3002
This product and its features are subject to state availability and may vary by state. Certain exclusions and limitations may apply. Guarantee Trust Life Insurance Company and United National Association are separate legal entities and have sole financial responsibility for their own products. Coverage is subject to termination in accordance with the Association Group Master Policy provisions. Notice of termination
provided to the Association is considered notification to all Association Members and will not be sent to you individually by GTL. The following rates apply for coverage underwritten by Guarantee Trust Life Insurance Company as part of your membership. The rates by plan are:
$10,000 Member Only = $3.50; $20,000 Member Only = $7.00
CONSENT TO ELECTRONIC DELIVERY: You have the option of downloading your certificate electronically. If you choose to do so, you are consenting to accept electronic delivery of your certificate.
GROUP TERM LIMITATIONS AND EXCLUSIONS
DEATH BENEFIT: We will pay a Death Benefit to the Beneficiary if a Covered Person dies while this Certificate is in force and before the Date
Certificate Ends as shown in the Schedule of Benefits. Subject to the terms and provisions of this Certificate, the Death Benefit will be theamount of life insurance payable as shown on the Schedule of Benefits. (renewable term)
*Please see certificate for specific Spouse and Child(ren) benefits (if applicable)
SUICIDE EXCLUSION: If a Covered Person dies as the result of suicide or any attempt at suicide, while sane or insane within two years of his Effective Date of coverage, the insurance company will be liable only for an amount equal to the Premium paid.
ACCIDENTAL DEATH BENEFIT AND EXCLUSIONS: The Accidental Death Benefit is paid directly to your beneficiary in a lump sum amount if you experience a covered loss resulting from an accidental injury, if the injury causes death within 90 days from the date of the accident.
This benefit is subject to all the terms, conditions, and exclusions of this Certificate.
EXCLUSIONS: No benefits are payable for any loss caused by:
 Suicide or intentionally self-inflicted Injury while sane or insane.
 War or any act of war, declared or undeclared.
 Travel, or flight in or descent from any kind of aircraft unless as a fare paying passenger on a regularly scheduled flight.
 As a passenger on an official flight of the Military Airlift Command of the United States or similar air transport services of other countries.
 Infections, except infections which occur simultaneously with or through a cut or wound sustained as the direct result of an Injury, independent of any other cause; and
 The non-accidental ingestion of a contaminated substance.
 Intoxication as defined in the jurisdiction where the accident occurred.
 Being under the influence of any drug unless administered and taken as prescribed by a Doctor.
 Participation in an attempt to commit an assault or felony, or participation in a riot.
 Voluntary gas inhalation or poison voluntarily taken, administered or inhaled.
 Riding or driving as a professional in any kind of race for prize money or profit.
CANCELLATION POLICY: If a member is not 100% satisfied with the product(s) they purchased; they may contact Member Services for cancellation within 30 days of purchase. Coverage will be cancelled as of the effective date and a refund of premium will be issued unless a claim has been submitted. A member may terminate the scheduled payments for insured and non-insured products by notifying Member Services five (5) business days prior to the next scheduled payment date via email at info@globalbenefitadmin.com or by calling Member Services at 1-877-222-9923.
REFUND POLICY: Refunds are subject to review; if claims have been submitted and are in process, a refund may not be applicable. By submitting a claim during the first 30 days under any of the insurance plans included with this enrollment, Members acknowledge and agree that such a submission constitutes acceptance of the membership, the products, and their terms and submission of such a claim constitutes a waiver of any and all refund rights, including those noted in the foregoing paragraph.
FRAUD WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person submits an insurance application or statement of claim containing any materially false, incomplete or misleading information may be committing a crime and may be subject to civil or criminal penalties.
POLICY TERMS & CONDITIONS: GlobalBenefit Administration Services provides administration and management services to agents, associations and carriers nationwide. Benefits Network, Inc. collects premium and other fees for your product.
Member enrollments include an electronic or physical signature or a recorded verification script which is required with each sale. The purpose of this signature or verification is to ensure that the Member understands, among other things, what product they are purchasing, what benefit are included with that product, how much they are paying at the initial time of sale, how much they will pay monthly thereafter, and that all subsequent monthly payments will be automatically drafted from the credit or banking account provided by the Member.
Each Member agrees that they are signing up for benefits or services that include an automatic payment plan. Each Member expressly authorizes Benefits Network, Inc. to automatically debit their bank account or Credit Card on the payment due date provided to collect any and all fees and membership dues for their membership. Each Member acknowledges and agrees upon the membership effective date and the
initial payment amount (this is comprised of the first month’s membership dues plus a one-time, refundable association membership processing fee). Each Member also acknowledges and agrees that their monthly dues will be automatically charged or drafted every month from the credit card, debit card or bank account they provide to us. If the effective date falls on a weekend or holiday, they understand that the payments may be executed on the prior business day. Further, each Member attests that they are the holder of the credit card, debit card or bank account provided.
Each Member agrees that if any such charge is dishonored, whether with or without cause and whether intentionally or inadvertently GlobalBenefit Administration Services, Benefits Network, Inc., the insurance carrier, the bank or credit card company shall be under no liability whatsoever even though it may result in forfeiture of their plan. Each member agrees that GlobalBenefit Administration Services, is authorized
to contact them via phone, text or email regarding payments.
Benefits are limited to the usual, reasonable and customary charge for each covered expense, in addition to any specific limits stated in the product policy documents.

By providing my signature below, I attest that I have read and understand the above policies. I agree that I have a full and complete understanding of the membership benefits and services for which I am applying. I acknowledge and agree that if there is any discrepancy between what I thought the enrolling agent told me about the membership plan purchased and what the actual Membership and Group policy (or policies) state, the policy terms govern. I certify that I am the applicant listed above and I elect to enroll and be billed for the selected membership and one-time enrollment fee.

FOR INTERNAL USE ONLY