William Penn Life, 2011 (46. évfolyam, 1-12. szám)
2011-07-01 / 7. szám
New Jersey Senior Citizens - Third Party Notice A third party may be designated to receive a copy of any cancellation, non renewal or conditional renewal and lapse notice from the William Penn Association by a person who: • is located in or is a resident of the State of New Jersey; • is insured by a Life, Annuity or health insurance certificate, contract or policy that the William Penn Association has issued; and • is age 62 or older. A third party may be designated by: completion of the information requested in the Third Party Designation below; and, return of the Third Party Designation Form to the William Penn Association by certified mail, return receipt requested. The designation will be effective upon our receipt of the information. Designation of a third party does not constitute the acceptance of any liability for the services provided to the person by the third party or by the William Penn Association. The third party designation may be terminated by: the third party by written notice to both the person and to the William Penn Association; or, the person by written notice to the William Penn Association. Third Party Designation Certificate/Contract/Policy Number:_______________________________________ Date:__________________________ Third Party Notice, Designee (Print Name):_________________________________________________________________ Address:--------------------------------------------------------------------------------------------------------------------I accept designation as a third party. Signature:_______________________________________________________________ Signature, Insured/Owner:-----------------------------------------------------------------------------------------------------------------------Tvent facíCítíes for aCCoccasions For more information, call 1-800-848-7366, ext. 103, or visit us on the Internet at www. scenicviewpa. com Cabins and Lodges in the Laurel Highlands William Penn Life 0 July 2011 0 17
