Insurance Ancillary Applications

INSURANCE ANCILLARY APPLICATIONS

Use this form to apply for ancillary insurance coverages to be attached to an existing primary policy or issued as supplemental benefits. Completion of all fields and the declaration at the end is required for underwriting and issuance. The applicant certifies that the information supplied is true, complete and correct to the best of the applicant's knowledge.

Applicant / Insured Information

Policy Details

Insurer Name:

Policy Period (End):

Ancillary Coverages — Selection

Select the ancillary coverages to be applied for. For each selected coverage, specify the requested limit or benefit amount and the desired effective date where applicable.

Exclusions and Limitations

The following are typical exclusions that may apply to ancillary coverages: (a) loss arising from intentionally self-inflicted injury, (b) loss due to participation in illegal activities, (c) pre-existing conditions as defined in the policy or rider language, (d) treatment received outside the scope of customary medical practice, and (e) losses subject to other valid insurance or subrogation rights. Additional exclusions and benefit conditions will be set forth in the issued rider or endorsement. The carrier reserves the right to apply limiting definitions, waiting periods, and benefit caps consistent with underwriting guidelines.

Beneficiary Designation (if applicable)

Supporting Information

Declaration, Authorization and Certification

By signing below the Applicant certifies under penalty of perjury that all statements made on this application are true and complete. The Applicant authorizes the insurer and its representatives to obtain and review records and information necessary to evaluate eligibility, underwriting, and claims, including but not limited to medical records, employment records and other relevant data. The Applicant acknowledges that coverage will be subject to the terms, conditions, limitations and exclusions of the insurance policy, rider or endorsement issued, and that the insurer may rely upon the information provided for underwriting and premium determination.

The Applicant understands and agrees that any material misrepresentation, omission, or concealment of facts may give the insurer grounds to rescind coverage, deny a claim, or adjust benefits as permitted by the policy and applicable law. The Applicant also consents to any lawful exchange of information among the insurer, reinsurers, administrators, and other entities involved in placing or administering the coverage for the purposes described above.

Arbitration: Unless otherwise required by law, disputes arising out of or relating to this ancillary application or any resulting endorsement may be resolved by binding arbitration in accordance with the carrier's rules applicable at the time of dispute. Waiver of jury trial and other rights may apply where permitted by law.

Acknowledgement: I acknowledge that I have read and understand the statements above and that submission of this application does not guarantee coverage until the insurer issues an endorsement or rider and the required premium is paid.

Documentation Checklist

Please attach copies of the following as applicable: proof of identity, proof of primary policy, recent paystubs or wage statements (for disability benefits), medical reports if required by underwriting, and any beneficiary documentation. Failure to provide required documentation may delay processing.

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