Insurance Application with Dependent

INSURANCE APPLICATION WITH DEPENDENT

Applicant Name:   Date of Application:

Applicant Information

Dependent Information

Dependent 1 Name:   DOB:   Relationship:

Dependent 2 Name:   DOB:   Relationship:

Policy Details

Coverage Selections

Please select coverage types to be included in the policy and indicate limits where applicable.

Beneficiary Designation

Prior Insurance & Loss History

Have you had prior insurance in the last 5 years?    Yes    No

Health and Eligibility (If Applicable)

Applicant or dependent has any of the following pre-existing conditions? (select all that apply)

Exclusions, Limitations, and Acknowledgements

The applicant acknowledges that coverage is subject to policy terms, conditions, exclusions, and limits. The following matters are specifically understood and agreed:

• Pre-existing conditions may be excluded or limited for a specified waiting period.
• Certain losses arising from intentional acts, fraud, or illegal conduct are excluded.
• Coverage is contingent upon receipt of premium and completion of underwriting requirements.

Authorization and Certification

I certify that the information in this application is true, complete and correctly recorded to the best of my knowledge. I authorize the insurer, its representatives and any medical or other providers to obtain and disclose to each other any records or information required to evaluate this application, administer the policy and investigate claims. I understand that any material misrepresentation or omission may result in denial of coverage, rescission of the policy or other remedies available to the insurer under law.

I further authorize payroll deduction, direct billing, or electronic funds transfer for premium payments where applicable and agree that coverage, if issued, is effective only when the insurer accepts this application in writing and receives any required premium.

Agent / Producer Information (If Applicable)

Additional Remarks / Underwriting Notes

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