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Prior PLI

Residents of California, Florida, Texas, and New York - enrollment is not available via Monthly or Bi-Weekly payments

Coverage Plan * $100,00 Admin Defense / $1,000,000 Liability $200,00 Admin Defense / $1,000,000 Liability $100,00 Admin Defense / $2,000,000 Liability $200,00 Admin Defense / $2,000,000 Liability $100,00 Admin Defense / $3,000,000 Liability $200,00 Admin Defense / $3,000,000 Liability

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Terms and Conditions

I hereby apply for coverage under CareerGuard® for which I am eligible as an employee of the Federal Government in good standing.  It is understood that any act, error or omission, allegation or knowledge thereof that occurs prior to the effective date and/or retroactive date of coverage will not be covered by the policy.  Policy is issued on an annual basis and is payable for the complete annual policy. No refund of premium except for retirement/resignation.  I have read above fraud statement for my state if applicable.  Policy is not bound or in force until you are issued policy documentation.  A $35 Cancellation Fee will be charged if policy is cancelled within the 1st year for reasons other than retirement.

I agree to the Terms & Conditions set forth above.

I hereby apply for coverage under CareerGuard® for which I am eligible as an employee of the Federal Government in good standing.  It is understood that any act, error or omission, allegation or knowledge thereof that occurs prior to the effective date and/or retroactive date of coverage will not be covered by the policy.  Policy is issued on an annual basis and is payable for the complete annual policy. No refund of premium except for retirement/resignation.  I have read above fraud statement for my state if applicable.  Policy is not bound or in force until you are issued policy documentation.

I agree to the Terms & Conditions set forth above.

I hereby apply for coverage under CareerGuard® for which I am eligible as an employee of the Federal Government in good standing.  It is understood that any act, error or omission, allegation or knowledge thereof that occurs prior to the effective date and/or retroactive date of coverage will not be covered by the policy.  Policy is issued on an annual basis and is payable for the complete annual policy.  No refund of premium except for retirement/resignation.  I have read above fraud statement for my state if applicable.  Policy is not bound or in force until you are issued policy documentation.  A $35 Cancellation Fee will be charged if policy is cancelled within the 1st year for reasons other than retirement.

I agree to the Terms & Conditions set forth above.

I hereby apply for coverage under CareerGuard® for which I am eligible as an employee of the Federal Government in good standing. It is understood that any act, error or omission, allegation or knowledge thereof that occurs prior to the effective date and/or retroactive date of coverage will not be covered by the policy.  Premium is 100% earned and policy is issued on an Annual basis regardless of payment cycle.  No refund of premium except for retirement/resignation.  Policy is not bound or in force until you are issued policy documentation.  It is also agreed premium payments will be debited from my bank as listed above on the payment cycle chosen.  I acknowledge a service charge of $35 will be incurred for any returned payment.  This AutoPay will stay in force until withdrawn in writing by me.  I have read above fraud statement for my state if applicable.   A $35 Cancellation Fee will be charged if policy is cancelled within the 1st year for reasons other than retirement.

I agree to the Terms & Conditions set forth above.

Fraud Notice

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 of a crime and may be subject to fines and confinement in prison.

NOTICE TO ALABAMA APPLICANTS AND CLAIMANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines, or confinement in prison, or any combination thereof.

NOTICE TO ALASKA CLAIMANTS: 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.

NOTICE TO ARIZONA CLAIMANTS: For your protection Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND AND WEST VIRGINIA APPLICANTS AND CLAIMANTS: 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.

NOTICE TO CALIFORNIA CLAIMANTS: For your protection, California law requires the following to appear on this form: 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.

NOTICE TO COLORADO APPLICANTS, POLICYHOLDERS AND CLAIMANTS: 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.

NOTICE TO DELAWARE CLAIMANTS: 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.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS AND CLAIMANTS: WARNING: 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.

NOTICE TO APPLICANTS OF FLORIDA AND CLAIMANTS: 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.

NOTICE TO IDAHO CLAIMANTS: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

NOTICE TO INDIANA CLAIMANTS: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

NOTICE TO APPLICANTS OF 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.

NOTICE TO MAINE APPLICANTS AND CLAIMANTS: 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 a denial of insurance benefits.

Surplus Lines Tax Notice

"I have agreed to the placement of coverage in the surplus lines market. I understand that superior coverage may be available in the admitted market and at a lesser cost and that persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolent unlicensed insurer".

The statute does not require the retail/producing agent to sign the form. However, the retail/producing agent should keep the original signed form in the insured\'s file in the event of a future E&O claim. The statute clearly states that if the form is signed by the insured that the insured is presumed to have been informed and to know that other coverage may be available and that the retail/producing agent has no liability for placing the policy in the surplus lines market.');

Some surplus lines brokers may ask for copies of these forms, but they are not required by statute to obtain or maintain these forms. Retail/producing agents may choose to comply with their requests for copies of the forms, but agents and brokers should note that the Florida Surplus Lines Service Office will not be looking for copies of these forms during compliance reviews of the files of surplus lines brokers. Only when a surplus lines broker acts in both a retail/producing agent capacity and a surplus lines broker capacity on a given risk/policy should the broker maintain a copy of this form.

Surplus Lines Disclosure and Acknowledgement

At my direction, CareerGuard/Berkley Alliance, has placed my coverage in the surplus lines market. As required by Florida Statute 629.916, I have agreed to this placement. I understand that superior coverage may be available in the admitted market and a lesser cost and that persons insured by surplus line carriers are not protected by the Florida Insurance Guaranty Association with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

I further understand the policy forms, conditions, premiums, and deductibles used by surplus lines insurers may be different from those found in policies used in the admitted market. I have been advised to carefully read the entire policy.

Consistent with the requirements of the New York Insurance Law and Regulation 41 you are hereby advised that all or a portion of the required coverages have been placed by Mass Benefits Consultants, Inc. with insurers not authorized to do an insurance business in New York and which are not subject to supervision by this State. Placements with unauthorized insurers can only be made under one of the following circumstances:

a) A diligent effort was first made to place the required insurance with companies authorized in New York to write coverages of the kind requested; or

b) NO diligent effort was required because i) the coverage qualifies as an "Export List" risk, or ii) the insured qualifies as an "Exempt Commercial Purchaser."

Policies issued by such unauthorized insurers may not be subject to all of the regulations of the Superintendent of Financial Services pertaining to policy forms. In the event of insolvency of the unauthorized insurers, losses will not be covered by any New York State security fund.

1. The insurance policy that you are applying to purchase is being issued by an insurer that is not licensed by the State of California. These companies are called "nonadmitted" or "surplus line" insurers.

2. The insurer is not subject to the financial solvency regulation and enforcement that apply to California licensed insurers.

3. The insurer does not participate in any of the insurance guarantee funds created by California law. Therefore, these funds will not pay your claims or protect your assets if the insurer becomes insolvent and is unable to make payments as promised.

4. The insurer should be licensed either as a foreign insurer in another state in the United States or as a non-United States (alien) insurer. You should ask questions of your insurance agent, broker, or "surplus line" broker or contact the California Department of Insurance at the toll-free number 1-800-927-4357 or internet website www.insurance.ca.gov. Ask whether or not the insurer is licensed as a foreign or non-United States (alien) insurer and for additional information about the insurer. You may visit the NAIC's internet website at www.naic.org. The NAIC - the National Association of Insurance Commissioners - is the regulatory support organization created and governed by the chief insurance regulators in the United States

5. Foreign insurers should be licensed by a state in the United States and you may contact that state's department of insurance to obtain more information about that insurer. You can find a link to each state from this NAIC internet website: https://naic.org/state_web_map.htm.

6. For non-United States (alien) insurers, the insurer should be licensed by a country outside of the United States ans should be on the NAIC's International Insurers Department (IID) listing of approved nonadmitted non-United States insurers. Ask your agent, broker, or "surplus lines" broker to obtain more information about that insurer.

7. California maintains a "List of Approved Surplus Line Insurers (LASLI)". Ask your agent or broker if the insurer is on that list, or view that list at the internet website of the California Department of Insurance: https://www.insurance.ca.gov/01-consumers/120-company/07-lasli/lasli.cfm.

8. If you, as the applicant, required that the insurance policy you have purchased be effective immediately, either because existing coverage was going to lapse within two business days or because you were required to have coverage within two business days, and you did not receive this disclosure form and a request for your signature until after coverage became effective, you have the right to cancel this policy within five days of receiving this disclosure. If you cancel coverage, the premium will be prorated and any broker\'s fee charged for this insurance will be returned to you.

Signature

Use your mouse or touchscreen (if applicable).  Then click Save Signature before Submitting.

Thank you for joining CareerGuard® Professional Liability Insurance Plan.  Your enrollment form has been received and you have elected to pay your premiums through payroll deduction.  Your coverage will be effective on the day your enrollment form was received, provided we receive your first allotment payment during that same pay period of your effective date.

You must start your payroll allotment through Employee Express, EPP, or My Pay, as we cannot start the allotment for you. Our banking information you will need to start the deduction is as follows:


If you do not have online access to your Earnings & Leave (click here to download the Direct Deposit Sign-up Form), you must complete the Direct Deposit Form attached and submit it to your payroll office. Also, please monitor your pay stubs to be sure the deduction has started.

If you have any questions, please feel free to call 1-800-221-3083.

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Next Steps

• Select Your Payroll Allotment (links below)
• Employee Express
• Employee Personal Page
• My Pay
• Direct Deposit Sign-up Form [Download PDF]
• When we receive the first allotment payment, your Certificate of Insurance and policy documents will be emailed to you.
• Please allow 2 weeks from when you see the first deduction on your Earnings and Leave statement.

Thank you for joining CareerGuard®.