\r\n\r\n \r\n\r\n \r\n\r\n
\r\n\r\n \r\n \r\n Select the benefit coverage option(s)
| Benefit | \r\nPremium | \r\n
|---|
Member's existing benefits on record.
\r\n View more information about each benefit at| Current benefit(s) | \r\nPremium | \r\n
|---|
\r\n ${props.currentMonthlyPremium}/month\r\n
\r\nSelect a premium payment option *
\r\nSelect the benefit coverage option(s)
}\r\n| Benefit | \r\nPremium | \r\n
|---|
\r\n In submitting this application to ASSI for coverage, I understand that if my application is\r\n accepted, my contract will consist of the Policy issued to me, along with a Policy Schedule\r\n containing information about my coverage, such as my premium and effective date.\r\n I understand that I am required to pay the monthly premium for the duration of the contract.\r\n I\r\n further agree that the coverage requested is subject to the approval of ASSI, that no\r\n coverage\r\n shall become effective until ASSI receives my initial premium, and that no representative\r\n has\r\n authority to make changes or modify this application.\r\n
\r\n I certify that all of the information contained in this application is true and correct to\r\n the\r\n best of my knowledge. I further understand that misrepresentation of submitted data may\r\n cause\r\n this application and subsequent Policy to be null and void. I understand that the Policy\r\n will\r\n become effective on the first day of the month following approval of this application and\r\n ASSI’s\r\n receipt of the initial premium.\r\n
\r\n By my submission of this application, I attest that I am a resident of a nursing,\r\n residential\r\n care, or assisted living facility in Arkansas.\r\n
\r\n Any person who knowingly presents a false or fraudulent claim for payment of a loss or\r\n benefit\r\n to an insurer or knowingly presents false information in an application for insurance is\r\n guilty\r\n of a crime and may be subject to fines and confinement in prison.\r\n
Select an option below to Print or Save a copy of the completed\r\n form.
\r\n\r\n Confirmation Number:\r\n
\r\n If you have questions about how to obtain the Member Number, call