Insurance Family Application

INSURANCE FAMILY APPLICATION

Applicant Name:    Date of Birth:    Identification Number:

Family Members to be Insured

List each family member to be covered. Provide full legal name, relationship, and date of birth.

1. Full Name:    Relationship:    DOB:

2. Full Name:    Relationship:    DOB:

3. Full Name:    Relationship:    DOB:

4. Full Name:    Relationship:    DOB:

If additional family members require coverage, attach a separate sheet with the same information and initial here:

Policy Details Requested

Policy Type:   Term Life    Whole Life    Family Health    Dental    Vision

Payment Frequency:    Monthly    Quarterly    Annual

Requested Policy Period From:    To:

Coverages and Optional Riders

Select coverage components to be included under the policy.

Accidental Death Benefit    Critical Illness Rider    Maternity Coverage

Family Dental    Vision    Prescription Drug Coverage

Include all listed dependents:   Limitations or special endorsements requested:

Exclusions and Limitations

The policy will exclude coverage for loss, expense, or treatment arising from: intentionally self-inflicted injury, pre-existing conditions as defined in the policy, participation in criminal activity, war or acts of war, and involvement in professional competitive sports. Coverage for specific conditions may be limited or excluded by endorsement. Applicant acknowledges that exclusions, waiting periods, and limitations will be set forth in the issued policy and that coverage is not effective until the insurer accepts this application and any required premium is paid.

Applicant initial to acknowledge receipt and understanding of standard exclusions:

Beneficiary Designation

Primary Beneficiary Name:    Relationship:    Share (%):

Contingent Beneficiary Name:    Relationship:    Share (%):

Medical and Underwriting Declarations

For Applicant and each family member proposed for coverage, answer the following. If yes, provide details in the space provided below.

1. Within the past 5 years, has any proposed insured been diagnosed with or treated for cancer, heart disease, stroke, diabetes requiring insulin, or any other chronic condition?   Yes   No

2. Has any proposed insured been advised to have surgery or hospitalization that has not yet occurred?   Yes   No

Documentation Checklist

Applicant must submit the documents indicated below with this application.

Proof of identity for applicant (photo ID)

Proof of residence

Medical records or examination form (if required)

Prior insurance policy documents (if replacing existing coverage)

Declaration and Authorization

I, the undersigned Applicant, represent that the statements and answers contained in this application are true, complete and correctly recorded to the best of my knowledge. I understand that any materially false statement or omission in this application may result in denial of coverage or rescission of the policy as permitted by law and the terms of the policy. I authorize any physician, medical practitioner, hospital, clinic or other health care provider that has attended me or any proposed insured to furnish to the insurer or its authorized representative any and all medical information, records and history concerning the proposed insured.

I authorize the insurer to obtain consumer reports, motor vehicle records, or other investigative reports as necessary for underwriting. I acknowledge that coverage will not become effective until the insurer has accepted the application and any required premium has been paid. I consent to the release of information as necessary for claims administration, underwriting, and fraud prevention.

Fraud Warning: Any person who knowingly presents false information in an application for insurance may commit a fraudulent act and may be subject to civil and criminal penalties under applicable law.

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