Insurance Application

Plateau Casualty Insurance Company

Home Office: 2701 North Main Street, Crossville, TN 38555

Administrative Office: P.O. Box 7001, Crossville, TN 38557-7001 

931-484-8411    800-752-8328


The individual applicant named below hereby makes application for the following insurance coverages:




Benefits are subject to all terms and conditions in the Certificate of Insurance and Certificate Schedule of Insurance.

Applicant Name:





Daytime Phone:

Evening Phone:


Applicant’s Date of Birth: 


I understand that this insurance is optional.

I understand that Benefit Amounts under this Insurance are payable directly to me. I understand that Benefit Amounts may have limits.

I understand that no benefits will be paid until the Vesting Period and Elimination Period, if any,  have been satisfied.

I understand that I am required to be employed at least thirty (30) hours per week for the ninety (90) day period immediately preceding the date my Involuntary Unemployment begins. Any change in my employment status, including, but not limited to, my retirement, may result in ineligibility for Involuntary Unemployment Insurance. If I become ineligible as a result of a change in employment status, I should contact the Administrative Office.

I understand that there are additional eligibility requirements, including, but not limited to, dollar limits, time restrictions and exclusions that could delay or even prevent payment of Benefits. I should read my Certificate of Insurance for a complete explanation of these eligibility requirements.

I understand that this insurance is not a deposit, guarantee, or other obligation of my creditors. This insurance coverage is not insured by the FDIC or any other agency of the United States or my creditors.

By signing, I acknowledge that I have read and understand the meaning of the disclosures, and I am applying for the coverages indicated. Furthermore, I hereby certify that all of the information I have provided on this form is true and correct.

Printed Name of Applicant

Signature of Applicant

Fraud Warning: 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 subjects such person to criminal and civil penalties.