BestLife Insurance Application Form

BestLife Insurance Application Form

Recitals

WHEREAS, Applicant Name: (the "Applicant") seeks to apply for life insurance coverage with Insurer Name: (the "Insurer");

WHEREAS, the Insurer has established underwriting, premium collection, and policy issuance procedures and the parties desire to document the terms under which the Insurer will process this application and, if accepted, issue the requested policy;

NOW, THEREFORE, Applicant submits this Application and both parties acknowledge and agree to the terms, conditions and authorizations set forth in this document.

Applicant Information

Policy Requested

Policy type: Term Permanent Universal

Beneficiary Designation

Medical & Risk Information

In the past five years, has the Applicant been diagnosed with any serious medical condition? Yes No

Tobacco use in past 12 months? Yes No

Scope of Work (Insurer Obligations)

Payment Terms

Premium amount: $

Payment schedule: Monthly Quarterly Annual

Payment method: Credit card Bank transfer (ACH) Check

Late fee:

Term and Termination

Policy effective date:   Policy expiration date:

Either party may terminate any pre-acceptance processing of this application upon written notice to the other party. After policy issuance, termination shall occur only as specified in the issued policy or for nonpayment of premium following the Insurer's notice and grace period.

Confidentiality

All non-public personal information and underwriting information provided by Applicant to Insurer is confidential. Insurer may disclose such information only as reasonably necessary to its agents, reinsurers, service providers, or as required by law. Insurer shall use commercially reasonable safeguards to protect confidential information and shall not disclose Applicant's medical records or health information except as permitted under applicable privacy laws and for underwriting, claims processing, or policy administration.

Governing Law

This Application and any resulting policy shall be governed by the laws of the State of without regard to conflict of law principles.

Entire Agreement

This Application, together with any policy issued by Insurer and any endorsements or riders attached thereto, constitutes the entire agreement between the parties with respect to the matters addressed herein and supersedes all prior proposals, negotiations and agreements, whether written or oral, relating to the subject matter of this Application.

Declarations and Authorizations

By signing below, Applicant certifies that all statements and answers provided in this Application are full, complete and true to the best of Applicant's knowledge and belief. Applicant authorizes Insurer to obtain medical records and other information necessary to evaluate this Application and to disclose information to reinsurers and to persons or entities involved in the underwriting and administration of any policy issued. Applicant acknowledges that any material misrepresentation or omission may be a basis for denial of coverage or rescission of coverage in accordance with applicable law.

I attest under penalty of perjury that the foregoing is true and correct. I agree

Agent/Producer Information

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