Globe Life And Accident Insurance Company is required by California Insurance Department regulations to gather demographic information about our California supplemental health insurance customers in order to provide you with a level of information about your policy in a written or spoken language that best meets your individual needs. For this reason, we are sending you the 2-question survey below pertaining to language and ethnicity. This information will not be used in any way to determine eligibility or insurability, rather to provide services you may require and to comply with this California law.

1.

Please enter your policy number from the letter you received. *

2.

Please choose your spoken preferred language below. This will help us to meet the written and spoken language needs of all of our California policyholders. *

3.

If your language was "Other" please write it below.

4.

Please choose your preferred written language from the dropdown menu. *

5.

If your language was "Other" please write it below. *