Individual Life Insurance Application for Reinstatement with Evidence of Insurability

Application for Reinstatement with Evidence of Insurability

Good Order Checklist: Use this checklist to make sure you have provided all the information required to evaluate your application for reinstatement. Complete and sign the forms in blue or black ink; do not use pencil or correction fluid. Do not send any payment with this application. Missing or incomplete information will lead to processing delays.

Important: All signatures on this application must be physical signatures. We cannot process requests signed using electronic signatures or signature fonts.

Forms contained in this package:

☐ Authorization for Release of Health-Related Information (HIPAA Compliant)

☐ Application for Reinstatement with Evidence of Insurability

☐ Part I-A. Reinstatement Request

☐ Part I-B. Primary Insured Information

☐ Part I-C. Other Insured Information

☐ Part I-D. Personal History

☐ Part I-E. In Force/Replacement Information

☐ Part I-F. Financial Details

☐ Part I-I. Acknowledgements, Certifications, Authorizations and Representations

☐ Part I-G. Notes

☐ Part I-J. Agent Signatures

☐ Application for Reinstatement with Evidence of Insurability Part II - Medical Declarations

AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION (HIPAA compliant)

PROPOSED INSURED INFORMATION (Please print.)

Proposed Insured Name:

Birth Date:

AUTHORIZATION INFORMATION

This will authorize a physician, clinic or hospital to release medical information to the Life Insurance Carrier(s) named above.

The information to be released includes health-related information, medical records, treatment records, lab reports, and related information.

Description of Personal Representative’s Authority or Relationship to Proposed Insured:

Attorney in Fact Grandparent Guardian Parent Other

APPLICATION FOR REINSTATEMENT WITH EVIDENCE OF INSURABILITY

Part I - A. Reinstatement Request

Policy Number:

Part I - B. Primary Insured Information

First Name: MI: Last Name:

Birth Date: SSN: Birth State/Country:

Gender: M F

Residence Address:

City: State: ZIP:

Daytime Phone: Evening Phone:

Best Time to Call: Email:

Driver’s License Number:

Driver’s License State:

Name on Driver’s License:

Are you a U.S. Citizen? Yes No

Occupation/Duties:

Do you currently use or have you ever used tobacco or nicotine products? Yes No

If yes, indicate Type: Amount & Frequency: Month/Year Last Used:

Part I - C. Other Insured Information

First Name: MI: Last Name:

Birth Date: SSN: Birth State/Country:

Gender: M F

Residence Address:

City: State: ZIP:

Daytime Phone: Evening Phone:

Best Time to Call: Email:

Part I - D. Personal History

1. Armed forces / Reserves? Yes No Yes No

2. Travel or reside outside U.S./Canada? Yes No Yes No

3. Aircraft flights other than scheduled airline passenger? Yes No Yes No

4. Hazardous sports / avocations? Yes No Yes No

5. Racing or stunt driving? Yes No Yes No

6. Convicted or pending criminal proceeding? Yes No Yes No

7. Motor vehicle accidents or violations? Yes No Yes No

Part I - E. In Force/Replacement Information

Do you currently have life insurance in force or applied for? Yes No Yes No

Insurance Company: Policy Number:

Amount: Date Issued:

Part I - F. Financial Details

1. Policy in accordance with your insurance objectives? Yes No

2. Financial ability to continue premium payments? Yes No

3. Bankruptcy? Yes No

Bankruptcy Details:

Bankruptcy Type: Discharge Date:

Financial Summary

Primary Insured Annual Earned Income: Annual Interest and Other Income: Total Assets: Total Liabilities: Total Net Worth:

Other Insured Annual Earned Income: Annual Interest and Other Income: Total Assets: Total Liabilities: Total Net Worth:

Part I - G. Notes

Part I - I. Acknowledgements, Certifications, Authorizations and Representations

Acknowledgements and Agreement: By signing this application, I acknowledge and agree to the statements provided in the policy application.

3. Rescission for False Statements: The Company may seek to rescind coverage if any question was not answered truthfully.

6. No Waiver by Producer. The producer does not have authority to waive any question or requirement.

7. Signature. By signing this application, I am applying for a reinstatement of life insurance coverage.

8. Receipt of Disclosure and Forms. I received the required disclosures and notices.

9. Governing Law. The policy shall be governed by the laws of the state/territory in which it was delivered.

10. Jurisdiction. Any dispute shall be filed in the state or federal courts located in the state in which the policy was delivered.

Authorization and Representation

Investigative Consumer Reports requested? Yes

Daytime phone number: Contact time: to

Signature Section

Signed at (city, state):

Part I - J. Agent Signatures

Agent involved in request?

Writing Agent/Registered Rep. Name:

Writing Agent/Registered Rep. Signature: Date:

Agent State Lic. Number: Agent/Registered Rep. Number:

Part II - Medical Declarations

Primary Insured Name: Policy Number:

Other Insured Name:

Primary Insured

Height: Weight: Change in weight: Gain Loss No change

Weight change details:

Primary Physician/Facility Name:

Primary Physician/Facility Phone:

Primary Physician/Facility Address:

City: State: ZIP:

Date last seen: Reason:

Results of Consultation:

Other Insured

Height: Weight: Change in weight: Gain Loss No change

Weight change details:

Primary Physician/Facility Name:

Primary Physician/Facility Phone:

Primary Physician/Facility Address:

City: State: ZIP:

Date last seen: Reason:

Results of Consultation:

Family History

Father - Primary Insured

Mother - Primary Insured

Father - Other Insured

Mother - Other Insured

16. Taking medications or supplements? Yes No Yes No

Medication Name: Dosage: Frequency: Reason:

Medical Declarations - Questions 17 to 20

17. Any diagnoses in the past 10 years? Yes No Yes No

18. Any operations, tests, or hospitalizations in the past 5 years? Yes No Yes No

19. Current or past use of Ecstasy, marijuana, cocaine, amphetamines, barbiturates, hallucinogens, narcotics, or other drugs? Yes No Yes No

20. Details for yes answers:

Final Signature Section

Signed at (city, state):

Important Notices

Consumer reports may be used to evaluate eligibility for insurance and may include information about your health, finances, employment, and driving record.

MIB, Inc. may receive and share information with member companies as allowed by law.

Information Practices: We may collect medical and non-medical information from you and other sources to evaluate your application.