Insurance At Need Contract

INSURANCE AT NEED CONTRACT

Insurer Name:   Policy Number:

Applicant / Insured Information

Policy Details

Policy Type (select all applicable):

At-Need Funeral Expense Policy Term Life (funeral specified) Guaranteed Acceptance Other:

Policy Period: Commencing and ending unless earlier terminated in accordance with this contract.

Coverage Selections

Select specific services covered under this At Need contract:

Basic funeral services (professional services) Burial expenses (casket, interment) Cremation services Transfer and transportation of remains Monument / headstone allowance Repatriation / international transport Other (specify)

Beneficiary Designation

Primary Beneficiary Name:   Relationship:

Contingent Beneficiary Name:   Allocation (%):

Exclusions and Limitations

The insurer shall not be liable for payment under this contract for loss or expense caused by, contributed to, or resulting from:

1. Intentional self-inflicted injury or suicide during the specified contestable period;
2. Losses resulting from acts of war or active participation in unlawful acts;
3. Claims arising from material misrepresentation in the application; if material misrepresentation is found, benefits may be denied or contract rescinded to the extent permitted by law;
4. Any pre-existing condition expressly excluded if death occurs within the waiting period set forth in the policy schedule;
5. Expenses incurred without prior authorization where prior authorization is a condition of coverage under this contract.

Claims and At-Need Procedures

Required documentation for claim (check all submitted):

Death certificate Itemized funeral invoice Proof of identity for claimant Medical records or attending physician statement (if requested)

Payment Authorization

Payment Method:

Monthly check Bank draft (ACH) Credit card One-time payment

Representations, Warranties and Consent

The Applicant represents and warrants that all information provided in this application and any attachments is true, complete and correct to the best of the Applicant's knowledge. The Applicant acknowledges that any material misrepresentation or omission may result in denial of benefits, rescission of coverage, or adjustment of benefits to the extent permitted by law.

The Applicant authorizes the insurer to obtain medical or other records reasonably necessary to evaluate eligibility for this contract. The Applicant further consents to the release of medical information by providers for the purpose of underwriting and claims adjudication. This authorization survives the Applicant's death for purposes of claims investigation and adjudication.

This contract may include a contestability period during which the insurer may investigate representations and withhold payment or rescind coverage for material misrepresentations. After the contestability period provided by applicable law, coverage will be incontestable except for fraud or non-payment of premiums.

Assignment of benefits to a funeral provider is permitted only if expressly documented in writing. If benefits are assigned, payment will be made to the assignee subject to verification of services rendered and compliance with documentation requirements.

Cancellation, Rescission and Free-Look

The Applicant has the right to cancel this contract within a free-look period described in the policy schedule. Cancellation within the free-look period entitles the Applicant to a full refund of any premiums paid, subject to the insurer's verification procedures. After the free-look period, cancellation and rescission provisions set forth in the policy govern refunds, if any.

Acknowledgement and Certification

By signing below, the Applicant certifies that they are authorized to make the statements contained herein and that they understand the terms, coverages, exclusions and claims procedures of this Insurance At Need Contract. The Applicant further acknowledges receipt of a copy of this contract and of any required disclosures delivered at the time of application.

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