Insurance Application and ROI

INSURANCE APPLICATION AND RELEASE OF INFORMATION AUTHORIZATION

This Insurance Application and Release of Information Authorization (the "Application") is submitted by the Applicant below for the purpose of applying for insurance coverage and authorizing the release of information necessary to evaluate eligibility, determine premiums, and administer claims. Applicant certifies that all information provided is true, complete, and material to the risk to be insured. Intentional misrepresentation or omission may result in denial of coverage or rescission.

Applicant / Insured Information

Applicant Name:

Policy Details

Policy Type: Term Life Whole Life Health Property Auto Liability

Coverage Options and Riders

Select coverages to apply for (initial all requested):

Exclusions and Limitations

The policy sought will contain specific exclusions, conditions, and limitations including, without limitation, exclusions for intentional acts, fraudulent misrepresentations, criminal acts, wear and tear, and losses arising from conditions specifically excluded in the final policy. Applicant acknowledges that coverage will be governed solely by the terms and conditions of the issued policy and not by this Application.

Beneficiary Designation

Primary Beneficiary Name:

Health, Claims History and Authorization

Have you had any prior insurance claims in the last five years? Yes No

Do you have any existing medical conditions relevant to this application? Yes No

Release of Information Authorization (ROI)

I authorize any licensed physician, medical practitioner, hospital, clinic, insurer, employer, consumer reporting agency, or other entity that has records or knowledge of me or my health, employment, or other relevant information to disclose such information to the insurance company, its agents, reinsurers, and representatives for the purpose of underwriting, premium rating, policy administration, claims handling, and fraud investigation. This authorization includes, but is not limited to, medical records, diagnostic tests, treatment records, prescription history, employment records, and prior insurance claims.

Purpose of disclosure: underwriting, claim investigation, policy issuance and administration. I understand that information released pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by applicable privacy laws.

This authorization will remain in effect for two years from the date signed below unless I revoke it earlier by delivering a written notice to the insurance company. Revocation will not apply to information already released in reliance on this authorization prior to receipt of the revocation. I understand that a copy of this authorization is as valid as the original.

By signing below, I certify under penalty of perjury that the information provided in this Application is true and complete to the best of my knowledge. I understand that intentional misstatements or omissions of material fact may be grounds for denial of coverage, rescission, or criminal prosecution. I authorize investigation of any statements contained herein and the procurement of consumer reports or investigative consumer reports where applicable.

Certification

I understand that this Application does not bind the insurer to issue a policy. Approval is subject to the insurer's underwriting guidelines, receipt of required documentation, and payment of any required premium. If a policy is issued, coverage will be effective only as provided in the policy and any endorsements issued with it.

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