NAPFA DISABILITY INSURANCE APPLICATION


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NAPFA DISABILITY INSURANCE APPLICATION
Please complete the entire form to apply. All fields must be completed to submit. All information provided on this information sheet is confidential and will be used solely for the purpose of plan enrollment. Please add Rees_Hamner@Ryan-Insurance.net and John_Ryan@Ryan-Insurance.net to your address book or "safe list" to ensure emails are received.

LONG TERM GROUP DISABILITY INSURANCE (LTD):

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SHORT TERM GROUP DISABILITY INSURANCE (STD):

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BANK DRAFT AUTHORIZATION
Premiums are paid by monthly bank draft only.

I (we) hereby authorize Collegiate Peaks Bank to initiate a debit entry to my (our) checking/savings account at the Financial Institution indicated below, on or about the 11th of each month, and initiate adjustments (if necessary) for any transactions credited/debited in error. This authority will remain in effect until Ryan Insurance Strategy Consultants is notified by me (us) in writing to cancel it in such time as to afford Collegiate Peaks Bank and my (our) Financial Institution a reasonable opportunity to act on it.

In the event the attempted premium withdraw from your designated financial institution is rejected for non-sufficient funds a $20.00 charge will be assessed to your premium draft.

You may also Fax or Mail these forms to us at:

John Ryan, CFP®
Ryan Insurance Strategy Consultants
5690 DTC Boulevard
Suite 290-W
Greenwood Village, CO 80111
Fax 888-337-2291

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