Insurance Insurability Form

INSURANCE INSURABILITY FORM

Applicant / Insured Information

Proposed Policy Details

Requested policy type: Life Health Disability Long-Term Care Other

Medical History and Risk Factors

Have you ever been diagnosed with or treated for any of the following conditions? Check all that apply.

Heart disease / cardiac disorder
Cancer / malignant tumor
Diabetes
Chronic respiratory disease
Mental health disorder
Other medical condition

Tobacco or nicotine use within the past five years: Yes No

Alcohol use exceeding recommended limits in the past 12 months: Yes No

Occupation, Activities, and Hazards

Occupation / job title:

Do you routinely engage in high-risk activities? (aviation, diving, motor racing, professional sports) Yes No

Existing Insurance and Claims

Any claims, denials, or cancellations within the last 5 years? Yes No

Beneficiary Designation

Exclusions, Known Conditions, and Documentation

Required documentation checklist (provide copies with this form):

Government-issued photo identification
Relevant medical records / lab reports
Proof of income / employment (if applicable)
Copies of prior insurance policies / declarations

Authorization, Certification, and Notices

I certify that the statements and answers in this Insurance Insurability Form are complete and true to the best of my knowledge and belief. I understand that the insurer will rely on these statements in determining eligibility and premium rates. Any material misrepresentation, omission or concealment of fact may result in denial of coverage or rescission of the policy.

I authorize any physician, medical practitioner, hospital, clinic, or other medical or medically related facility or any insurance company, employer, group policyholder, consumer reporting agency, or other organization, institution or person that has records or knowledge of me or my health to release to the insurer or its authorized representative such information. This authorization includes, but is not limited to, medical records, diagnostic test results, and payment history relevant to the underwriting and claim evaluation of the proposed policy.

I acknowledge and consent that the insurer may obtain consumer reports, investigative consumer reports and may verify other information necessary for underwriting. I understand that the insurer will use information obtained for underwriting, claim handling, risk classification, and other lawful purposes.

I agree to promptly notify the insurer in writing of any change in health, occupation, residence, or activities that occur prior to policy issuance that may affect insurability. Coverage will not take effect until the insurer has completed underwriting and issued a policy or binding receipt as required under applicable underwriting rules.

A photocopy or electronic reproduction of this authorization shall be as valid as the original. This authorization shall remain valid for a period of 24 months from the date signed below unless earlier revoked in writing.

On this day: of ,

Applicant Certification

By signing below I declare under penalty of perjury that the information provided in this form is true, complete and correctly recorded. I understand that any intentional misrepresentation or fraud in the application may be grounds for denial, modification, or rescission of coverage and may be subject to civil or criminal penalties.

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