AFLAC Supplemental Insurance Program


The City and County of Broomfield offer voluntary supplemental Group and Individual insurance plans available through AFLAC for full time and eligible part time employees. 

Individual Plan

Group Plans

Forms

IMPORTANT INFORMATION

Please read before enrolling....  When you elect and enroll in one or more of the AFLAC Group plans, understand you are agreeing to the below certifications.


To the best of my knowledge and belief, the answers to the questions on this Enrollment Form are true and complete.  They are offered to Continental American Insurance Company as the basis for any insurance issued.  

If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy via direct bill. You should contact your insurance carrier for an explanation of your options for both continuation or cancellation of your existing coverage.

Coverage will not become effective unless you are employed full-time on the enrollment date and on the effective date.

CERTIFICATION: I have read the completed Enrollment Form and I realize any false statement or misrepresentation in the Enrollment Form may result in loss of coverage under the Certificate.  I understand that no insurance will be in effect until my Enrollment Form is approved and the necessary premium is paid.

I understand and agree that the coverage that I am applying for may have a pre-existing condition exclusion. 

I authorize my employer to deduct the appropriate dollar amount from my earnings each pay period to pay Continental American Insurance Company the required premium for my insurance.

A person is guilty of insurance fraud if he intends to defraud an insurer or if he knowingly facilitates a fraud against an insurer.  Fraudulent activities include submitting an Application or filing a claim that contains any false or deceptive statement.

Accident: I certify that I currently work full-time for the employer listed on this enrollment form and that my spouse is not currently disabled or unable to work.
 
Critical Illness: I certify that I currently work full-time for the employer listed on this enrollment form and that my spouse is not currently disabled or unable to work.  I further certify that neither my spouse nor I have used tobacco products in the last 12 months.
 
Hospital Indemnity: I certify that I currently work full-time for the employer listed on this enrollment form and that my spouse is not currently disabled or unable to work.


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.


Contact our Agent


For more information on any of these programs, please contact Lisa Perry at l_perry@us.aflac.com or 303.596.6119.