Globe Life and Accident Request for Policy Change

Globe Life And Accident Insurance Company
Request for Policy Change

Part 1

Application is hereby made to change the above numbered policy as indicated below. The policy is attached for such change.   Yes   No

TERM INSURANCE ONLY

Reduce amount or Convert coverage at attained age on life of

If this is a conversion of a term rider, the basic policy is to be continued, cancelled, and any cash value paid to me.

If all of the term insurance is not to be converted, the balance is to be continued, cancelled.

Any cash value of the converted portion of the term insurance is to be paid to me.

If additional insurance is desired, application is hereby made for of new insurance.

Automatic Premium Loan, if available. Yes No

PERMANENT INSURANCE ONLY

Reduce amount

ADDITIONAL BENEFITS

Additional benefit requests below apply to basic policy, new policy issued as a result of conversion request made above.

Add WP Delete Add Term Rider Add OPAI Delete Add Child Rider Delete

Instructions: Complete Part 2 when adding coverage on Primary Insured. Complete Parts 2 and 3 when adding a Child Rider.

OTHER REQUESTS

Remove or reduce extra rating. (Complete Part 2.)

Reinstate and redate. (Complete Part 2 and a regular Reinstatement Application GIRA-9R.)

Special Changes:

Corrections and Amendments (Home Office use only)

The policy changes herein requested shall not be effective until the application is approved, policy delivered, and any necessary payment has been received by the Company.

In any new policy issued at the attained age of the Insured on the basis of this application, the effective date referred to in the Incontestability and Suicide provision of the new policy shall be the Date of Issue on the original policy, except as pertains to the increased portion of the new face amount and extra benefits included in the policy for which the effective date shall be the effective date of the new policy.

The acceptance of any policy issued hereon shall constitute ratification of any and all changes in or additions to this application indicated by the Company in the space above entitled “Corrections and Amendments,” except that no change in amount, classification, age at issue, plan of insurance or benefits shall be effective unless agreed to in writing.

Part 2

Supplementary Application to Globe Life And Accident Insurance Company

COMPLETE THIS PART IF SO INSTRUCTED IN PART 1

Sex Birthdate Birthplace Payor Rank and Service

Payor SSN

Marital Status: Single Married Widowed Divorced Separated

Current mailing address

No. and Street

City State Zip

Permanent address

No. and Street

City State Zip

Health and lifestyle questions

3a. Engaged in or any intention of engaging in hang gliding, racing, scuba diving, or sky diving? Yes No

3b. Other life insurance applications pending? Yes No

3c. Life or health insurance declined, modified or rated? Yes No

3d. Intention of replacing or changing any life insurance or annuity policy? Yes No

3e. Pilot or crew member of military aircraft or made aerial flights? Yes No

3f. Received within the last year or expect to soon receive orders for duty outside the United States? Yes No

3g. Ever received treatment or joined an organization for alcoholism or drug addiction? Yes No

3h. In the past five years habitually used or currently use narcotic drugs or similar agents? Yes No

3i. Receiving any kind of treatment or taking any kind of medicine? Yes No

3j. Used tobacco within the last 12 months? Yes No

Quit date (Mo./Yr.)

3k. High blood pressure, diabetes, epilepsy, tumor, cancer, or disorder of major systems? Yes No

3l. Disease or disorder of the immune system? Yes No

3m. Any illness, injury, or surgery in the last five years? Yes No

Current height and weight: ft., in., lbs.

5. Remarks

AVIATION QUESTIONNAIRE

6. Type of license or Rating: Dates of Issue: Last Renewal: Last Flight:

7. Type of Flying Pilot Crew Member

Current Hours Flown in Past / Estimate of Future Hours

Total all flights Last 12 Mos. 1-2 Yrs. ago 2-3 Yrs. ago Next 12 Months

8. Instruction, stunt, aerobatic, racing, crop dusting, helicopter, glider, test, or home-built aircraft flying? Yes No

Give details:

I represent that all statements made above are true and complete to the best of my knowledge. I agree that such statements shall be the basis for the policy changes applied for in Part 1.

I acknowledge receiving the Pre-Notice and the “MIB” Disclosure Notice.

AUTHORIZATION

A photo copy of this authorization shall be as valid as the original. I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, the Medical Information Bureau or organization, institution or person, that has any records or knowledge of me or my health, or my children or their health, to give Globe Life And Accident Insurance Company or its reinsurers any such information.

This authorization shall be valid for two and one-half years from the date shown below.

Date Signature of Insured

Part 3

SUPPLEMENTARY APPLICATION FOR CHILD RIDER

9. Persons proposed for insurance

10. Has Proposed Insured:

a. Engaged in hang gliding, racing, scuba diving, or sky diving? Yes No

b. Other life insurance pending? Yes No

c. Ever had life or health insurance declined, modified or rated? Yes No

d. Intention of replacing or changing any life insurance or annuity policy? Yes No

e. Pilot or crew member of any aircraft, or made any aerial flights? Yes No

f. Ever received treatment or joined an organization for alcoholism or drug addiction? Yes No

g. Habitually used or currently use narcotic drugs or similar agents? Yes No

h. Receiving treatment or taking any medicine? Yes No

i. Used tobacco within the last 12 months? Yes No

Quit date (Mo./Yr.)

j. High blood pressure, diabetes, epilepsy, tumor, cancer, or disorder of major systems? Yes No

k. Disease or disorder of the immune system? Yes No

l. Any illness, injury, or surgery in the last five years? Yes No

11. Insurance in force and pending (If none, mark “none.”)

12. Remarks

I represent that all statements made above with respect to any persons proposed for insurance are true and complete to the best of my knowledge. Except with respect to any minor child, this application is made with the knowledge and consent of each person proposed for insurance.

I acknowledge receiving the Pre-Notice and the “MIB” Disclosure Notice.

AUTHORIZATION

A photo copy of this authorization shall be as valid as the original. I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, the Medical Information Bureau or other organization, institution or person, that has any records or knowledge of me or my health, or my children or their health, to give Globe Life And Accident Insurance Company or its reinsurers any such information.

This authorization shall be valid for two and one-half years from the date shown below.

Date Signature of Primary Insured

PRE-NOTICE

Detach this notice and leave it with Primary Insured.

In making this application for insurance it is understood that an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics and mode of living. You have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigation. Your written request should be made to Globe Life And Accident Insurance Company, P.O. Box 8050, McKinney, Texas 75070.

“MIB” DISCLOSURE NOTICE

Detach this notice and leave it with Primary Insured.

Information regarding insurability will be treated as confidential. Globe Life And Accident Insurance Company or its reinsurers may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance companies which operates an information exchange on behalf of its members.

Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act.

AGENT’S REPORT

1. Effective month of allotment Desired policy date

Total premium quoted $ Amount paid with this application $

2. Have medical exams been arranged? Yes No If “Yes,” when and by what examiner?

3. Is any policy applied for on this application intended to replace any insurance or annuity now in force? Yes No

4. Are you related to any person proposed for insurance? Yes No

If “Yes,” give details.

5. If Proposed Insured is not now on active military duty, furnish primary occupation and employer’s name:

If total new insurance applied for on any one family member exceeds $200,000, please complete questions 6, 7, 8 and 9.

6. Telephone Numbers: Home (Area) During Day Yes No

Business (Area) Extension No. During Day Yes No

7. Is it satisfactory to contact other adult family members? Yes No

8. Most convenient time and place for interview call: Home Office Preferred Time: A.M. P.M.

9. Driver’s License: State Number

I hereby certify that I personally solicited this application, and that I have no knowledge of anything which might affect the insurability of any person proposed for insurance which is not fully set forth herein.

Agent’s Signature