Healthcare Life Application

HEALTHCARE LIFE APPLICATION

This Healthcare Life Application (the "Application") is submitted to request life coverage and to authorize the use and disclosure of protected health information for underwriting and claims purposes. Complete all sections fully and sign the certification and authorizations below. Failure to provide accurate information may result in denial of coverage or rescission in accordance with the insurer's terms.

Patient Information

Date of Birth:

Male Female Other / Non-binary Prefer not to answer

Emergency Contact

Insurance Information

Medical History

Have you been hospitalized or had surgery in the last five years? Yes No

Tobacco/Nicotine Use: Current user Former user Never used

Alcohol or Substance Use Concerns: Yes No

Height: Weight:

Requested Coverage & Beneficiaries

Requested Plan Type: Term Life Whole Life Universal Life

Authorization & Privacy

Authorization to Obtain and Disclose Health Information: I authorize any health care provider, medical professional, hospital, clinic, pharmacy, insurance company, or other entity that has my records or knowledge of me or my health to disclose such records and information, including medical history, diagnosis, treatment, prognosis, and claims information, to the insurer and its agents for underwriting, claim determination, policy administration, and reinsurance. This authorization includes disclosure of mental health, substance use disorder, and HIV-related information to the extent permitted by law.

Purpose of Disclosure: The information obtained pursuant to this authorization will be used to determine eligibility for coverage, set premiums, administer benefits, and for ongoing underwriting and claims review. I understand that the information disclosed may be subject to redisclosure by the recipient and no longer protected by privacy laws to the extent permitted by law.

I understand that I may revoke this authorization at any time by delivering a written revocation to the insurer, except to the extent that action has been taken in reliance on the authorization. Revocation does not affect disclosures made prior to receipt of the revocation. This authorization shall remain in effect until the authorization expiration date specified above, or until revoked, whichever occurs first.

Representations, Certification & Agreement

I certify that all statements made in this Application are full, complete and true to the best of my knowledge and belief. I understand that any material misrepresentation or omission may be grounds for rescission or denial of benefits. I acknowledge that the insurer may use and disclose information obtained pursuant to this Application for underwriting and claims adjudication.

I further acknowledge and agree that no coverage is effective until approved in writing by the insurer and until any required premium is accepted. Acceptance of any premium does not constitute acceptance of risk or issuance of coverage unless the insurer's underwriting conditions are satisfied.

By signing below I authorize payment of benefits, if any, as designated and certify that I have read and understand this Application, the authorization for release of medical information, and the statements contained herein.

HIPAA Acknowledgment: I acknowledge receipt of the insurer's privacy practices and authorize the use and disclosure of my protected health information for the purposes described above.

Sign Now