Insurance EOI and Invoice

INSURANCE EOI AND INVOICE

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Number:    Policy Type: Life Disability Critical Illness Accident Other

Deductible:    Premium Amount:

Policy Period From:    To:

Coverage Selection & Exclusions

Select additional coverage options (if applicable):
Accidental Death Benefit Terminal Illness Acceleration Premium Waiver for Disability

Exclusions: The insurer will not cover losses arising directly from intentionally self-inflicted injury, acts of war, active participation in a felony, or hazardous activities specifically excluded by endorsement. Any material misrepresentation or omission in this Evidence of Insurability may void coverage or affect claim payment.

Evidence of Insurability — Medical & Health Information

1. In the past 5 years, have you been diagnosed with, treated for, or had symptoms of any chronic illness, cancer, heart disease, stroke, diabetes, or any condition requiring hospitalization?   Yes   No

2. Are you currently taking any prescription medication?   Yes   No

3. Have you used tobacco or nicotine products in the past 12 months?   Yes   No

Physician Phone:    Last Exam Date:

Beneficiary Designation

Relationship:    Percentage of Benefit:

Invoice / Billing

Invoice Number:    Invoice Date:

Description:   Quantity:   Unit Price:   Amount:

Description:   Quantity:   Unit Price:   Amount:

Subtotal:    Tax:    Total Due:

Documentation Checklist

Copy of government-issued photo ID included
Relevant medical records / physician statement included
Proof of premium payment included
Other documentation (see notes)

Declarations, Authorizations & Certification

I certify that the information provided on this Evidence of Insurability and Invoice is true, complete and correctly recorded to the best of my knowledge. I understand that intentional misrepresentation or omission of material facts may result in denial of coverage or rescission of the policy. I authorize any physician, medical practitioner, hospital, clinic, pharmacy, or other medical facility to release to the insurer any information concerning my medical history, medical condition, or treatment. This authorization remains valid for the duration necessary to evaluate my application and any subsequent claim.

Applicant acknowledges that the insurer may rely on electronic or photocopied records when reviewing this submission. By signing below the applicant further authorizes the insurer to obtain records from third parties for underwriting and claim adjudication purposes.

Applicant Initials:

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