GROUP INSURANCE

Group Life insurance has been the biggest ‘buzz phrase’ with ZANC. We have been able to establish a stable and well structured Group Life Insurance partnership for our community, friends and family here in the diaspora. This has been and continues to be the largest benefit of joining ZANC and being a part of its social responsibility. We facilitate enrollment of all members and interested non-members, into an affordable group life-insurance scheme. Call us and we will gladly walk you through the process.

Group Insurance through

Zambians Association of Northern California

To Applicants:

Zambians Association of Northern California welcomes you as participants in the Group Life Insurance benefits.

Insurance Information:

$18.00 monthly insurance premium, paid semi-annually for a total of $108.00
$5 monthly fee for *outside Sacramento members, which should be paid semi-annually for a total of $30.
$10 monthly fee for Sacramento area residents totaling $120

(As an added saving, you can pay a one-time discounted fee of $100 for the whole year’s membership) P.s. This does not include insurance it is for “membership only”.

$0.60 monthly insurance premium for children under the age of 21. Please note that all children under 21 are not subject to membership fees.

YOUR INSURANCECOVERAGE

$20,000 for Adults
$7,500 for Children

Designated beneficiary must be based in the USA and be in possession of a valid Social Security number. If you do not have one, please contact the Association’s Secretary or any any member of the board for assistance.

Open enrollment period is on January 1st and June 1 each year – No prior medical test is required

APPLICATION FORMS: (APPLY ONLINE)

For further details and clarification Contact Mr. Mwengu Siwiti at (916) 425 1759, or Mrs. Kasamba Sikapizye at (845) 665 3953

YOUR PAYMENT OPTIONS:

Bank Deposit: Wells Fargo Bank Account Number 7185547853 Routing number 121042882
By check payable to ZANC.
PayPal Account: ZANC2016@gmail.com
ZELLE: Mr Mwengu Siwiti (916 425 1759)

CONTACT FOR FURTHER INQUIRIES:

President Mwengu Siwiti (916 425 1759) Treasurer (916) 627 8449 Musonda Kabwe

Secretary: Kasamba Sikapizye (845 665 3953) Vice President: Terry M Chisenga (916 912 0651)

Vice Treasurer: Ezekiel Sakala (916 308 6289) Vice Secretary (530 329 6321) Beene Naulapwa

We look forward to having as many persons insured as possible as it is the right thing to do in ensuring a dignified send-off.

Sincerely,

Terry Matikili Chisenga

Vice President

Zambians Association of Northern California

ZANC LIFE INSURANCE

Group Term Life Insurance

THE Insurance Programs Enrollment Form Group Term Life Insurance Plan

Policyholder Name: Cultural Group Insurance Trust (CGIT)

Participating Organization of: *

Group Billing #: *

Group Policy *

MEMBER Name: *

First

Middle

Last

Date of Birth *

Gender *

Male
Female

Social Security # *

Address *

Address Line 1

City

State

Zip Code

Primary Phone *

Secondary Phone (Optional)

Email *

MEMBER:

Proposed Insured Age	First Year Benefit Amount*	Maximum Graded Benefit Amount*
Under Age 65	Age 65-69	Age
$10,000	$5,000	$1,000
$20,000	$10,000	$2,000

*At age 65, your benefit amount will reduce to 50% of the basic amount. At age 70, your benefit amount will reduce to 10% ofthe basic amount.

CHILDREN COVERAGE: (Optional)

I wish to enroll in coverage for lily children: *

Children Coverage Amount (choose one):

$5,000
$7,500

*The benefit amount is determined by your participating Cultural Association.

DEPENDENT INFORMATION (If more than 5 children, Tick on Checkbox)

Child Name

Gender

Date of Birth

Social Security #

Child Name 2

Gender

Date of Birth

Social Security #

Child Name 3

Gender

Date of Birth

Social Security #

Child Name 4

Gender

Date of Birth

Social Security #

Child Name 5

Gender

Date of Birth

Social Security #

Increase Sheet Size

I have more than 5 Childrens

BENEFICIARY DESIGNATION

You must select your beneficiary - the person (or more than one person) or legal entitiy (or more than one entity) who receives a benefit payment if you die while covered by the plans. Please make sure that you also name a contingent beneficiary - who would receive your benefit if your primary beneficiary dies first. Please make sure your beenficiary designation is clear so that there will be no question as to your meaning. Ifyou name more than one primary or contingent beneficiary, show the percentage of your beenfit to be paid to each beneficiary. Please provide all ofthe information requested below. If your beneficiary is not related either by blood or by marriage, insert the words, "Not Related" as their stated relationship. Ifyou need assistance, contact your administrator or your own legal advisor. A primary beneficiary is the beneficiary or beneficiaries that you name to receive the benefits if they are living at the time ofyour death. The primary beneficiaries are the first in line to receive death benefits. Contingent beneficiaries, or secondary beneficiaries, are those named to receive the insurance proceeds if no primary beneficiary is alive at the time you die.

Primary Beneficiary(s)

Primary Beneficiary Name *

Social Security # *

Date of Birth *

Phone # *

Address *

Relationship *

Percentage *

Primary Beneficiary Name

Social Security #

Date of Birth

Phone #

Address

Relationship

Percentage

Contingent Beneficiary(s)

Contingent Beneficiary Name *

Social Security # *

Date of Birth *

Phone # *

Address *

Relationship *

Percentage *

Contingent Beneficiary Name

Social Security #

Date of Birth

Phone #

Address

Relationship

Percentage

The beneficiary for insurance on the lives of your dependents will automatically be you, ifsurviving. Otherwise, the beneficiary will be subject to policy provisions. A beneficiary for member's insurance may be changed upon written request.

EXISTING LIFE INSURANCE POLICY

By applying for this insurance, do you intend to replace, discontinue, or change an existing policy of life insurance? *

NOTIFICATION

I have the opportunity to enroll in the Hartforld Life and Accident Insurance Company Group Term Life Insurance Plan (AGL-1942). I certify that the above statements are full, complete, and true for each person to be insured, to the best of my/our knowledge and belief. I also understand that any misrepresentation contained herein or relied up on by the company may be used ot contest the validity of the coverage, within the contestable period if such misrepresentation materially affects acceptance of the risk. I understand and agree this insurance will go into effect upon receipt of my first premium payment and this form and remain in effect only in accordance with the provisions, terms and conditions of the insurance policy. I understand and agree that only the insurance policy issued to [Association] can fully describe the provisions, terms, conditions, limitations and exclusions of my insurance. In the event of any difference between the enrollment form and the insurance policy, I agree to be bound by the insurance policy.

Date of Birth *

Signature *

Apply for Zanc Membership

I also want to apply for Zanc Membership

SELECT PAYMENT OPTION (PAY BEFORE SUBITTING THE FORM) *

Bank Deposit: Wells Fargo Bank Account Number 7185547853 Routing number 121042882
By check payable to ZANC.
PayPal Account: ZANC2016@gmail.com

PAYMENT INVOICE NUMBER / EMAIL / ACCOUNT NUMBER (PROOF) *

THE APPLICATION WILL BE REJECTED IF THE INVOICE DETAILS ARE INCORRECT OR REUSED.

PAYMENT INVOICE SCREENSHOT (OPTIONAL)

Click or drag a file to this area to upload.

FRAUD NOTICE(S)

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty ofa crime and may be subject to fines and confinement in prison. For Residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony ofthe third degree. For Residents of Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For Residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For Residents of Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose ofdefrauding the company. Penalties include imprisonment, fines and denial of insurance benefits

Name

GROUP INSURANCE

ZANC LIFE INSURANCE

MEMBER:

CHILDREN COVERAGE: (Optional)

DEPENDENT INFORMATION (If more than 5 children, Tick on Checkbox)

BENEFICIARY DESIGNATION

Primary Beneficiary(s)

Contingent Beneficiary(s)

EXISTING LIFE INSURANCE POLICY

NOTIFICATION

NOTE: Children below 19 years, enjoy free membership by virtue of the active membership status of their parents. Active membership status is conditional upon being up-to-date with monthly subscriptions.

NOTE: You can do payment for both Group Term Life Insurance and Zanc Membership below

FRAUD NOTICE(S)