Application

Medical Coverage

You can apply on-line at:

Life, AD&D and LTD

All completed enrollment and application forms for Term Life, AD&D and LTD should be directed along with the appropriate premium payment to  Rutherfoord International Inc..

Premium payment calculation should be based on either a 6 or 12 month period of coverage. Payment can be made by check, money order, electronic transfer, or major credit card. All payments should be made to Global Benefits Group.

A single enrollment form should be completed for all individuals to be insured under one certificate.

Each individual to be insured under one certificate must complete a medical declaration.

Each individual who elects either the Term Life coverage, and/or Accidental Death and Dismemberment, and/or Long Term Disability, must complete the Life-AD&D- LTD medical declaration.

A single premium calculation table should be completed for all individuals to be insured under one certificate.

Forms can easily be downloaded and printed using the Adobe Acrobat Reader tool available, free of charge, on the Adobe website. Enrollment Form (including Questionaire for Medical)
Questionaire for Life, AD&D, LTD