Renaissance Application Agreement
By confirming your purchase, you are indicating your agreement to the following statements:
By clicking to e-sign this application, I am indicating my intent to sign this application electronically, and warrant that all of the information I have provided is true, complete and accurate.
I request coverage under a group insurance plan made available to Stride Health members. I will be provided a certificate of coverage in either electronic or paper form upon request. The electronic delivery of my certificate of coverage must be pursuant to the Terms for Paperless Delivery. Such terms provide the manner in which I can request a paper copy at any time.
Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Fraud Warning Notices: (If you live in a state where one of the fraud warning notices apply, please review the notice that applies to your state.)
Alaska: Any person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
Alabama/Arkansas/Louisiana/New Mexico/Rhode Island/West Virginia: 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.
Arizona: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
California: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.
Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
DC: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Delaware/Idaho/Indiana: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
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 of the third degree.
Georgia: A natural person convicted of a violation of insurance fraud shall be guilty of a felony and shall be punished by imprisonment for not less than two nor more than ten years, or by a fine of not more than ten thousand dollars, or both.
Hawaii: Any person who presents a fraudulent claim for payment of a loss or benefit is guilty of a crime punishable by fines or imprisonment, or both.
Kansas: Any person, who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact thereto, may be guilty of insurance fraud as determined by a court of law.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading,information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Maine/Tennessee/Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefit.
Maryland: Any person who knowingly or willingly presents a false or fraudulent claim for payment for a loss or benefit or who knowingly or willingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Minnesota: Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty.
New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
ASBA Membership
To purchase this Renaissance insurance plan, I understand I am agreeing to become a member of American Senior Benefits Association (ASBA). ASBA is a national non-profit association with over 800,000 members focused on education, advocacy and member programs for Americans.
ASBA membership is free, and the benefits are extensive.
Your free membership includes:
• Access to more than 30 member-only programs and discounts—including this Renaissance insurance offering
• $1,000 ASBA scholarship grant opportunities
• Tax tips
• Targeted advocacy and legislative updates from Washington DC
• Newsletters and special promotions featuring tips and information relating to your life