Insurance Insurability Request

INSURANCE INSURABILITY REQUEST

Use this form to request a preliminary determination of insurability for an applicant. Complete all sections accurately and sign the certification at the end. Submission of this request does not constitute acceptance or issuance of insurance; coverage is effective only upon formal approval and issuance of a policy by the insurer.

Applicant / Insured Information

Policy / Coverage Requested

Policy type requested: Life Health Disability Property Liability Other:

Current and Prior Insurance

Is the applicant currently insured with any carrier? Yes No

Have any applications been declined, cancelled, or rated in the past 5 years? Yes No

Health, Activities and Risk Declarations

Has the applicant ever had or been treated for any of the following? Check all that apply.

Cardiac or circulatory disorder
Cancer or tumor
Diabetes
Respiratory disease
Mental health or substance use disorder
None of the above

Tobacco or nicotine use in the past 12 months: Yes No

Does the applicant participate in hazardous activities (e.g., aviation, scuba diving, motor racing)? Yes No

Exclusions, Limitations and Underwriting Acknowledgement

The insurer may apply specific exclusions, rating factors, or restrictions based on the information provided and any supplemental investigations. The following are examples of common underwriting exclusions and limitations; this list is illustrative and not exhaustive. Final terms will be set by underwriting and documented in the policy.

• Pre-existing conditions may be excluded or limited for a specified period.
• Acts of war, participation in criminal activity, and intentional self-harm are commonly excluded.
• Hazardous occupations or avocations may be rated or excluded.
• Fraud, material misrepresentation, or omission may result in rescission of coverage or denial of benefits.

Acknowledgement: I acknowledge that final underwriting determinations, including exclusions and premiums, will be made following review of this request and any requested records.

Beneficiary Designation (If applicable)

Documentation Checklist

Please attach or provide the following, if applicable. Check each item included with this request:

Government-issued photo ID
Prior policy declarations / loss runs
Medical records release / physician statements
Proof of income or payroll (for disability/occupational underwriting)
Photographs / condition reports (for property)

Authorization and Certification

I certify that the information provided in this request is true, complete, and accurate to the best of my knowledge. I understand that any material misrepresentation or omission may void coverage or be grounds for rescission. I further understand that this request is for underwriting purposes only and does not bind the insurer to issue a policy.

I authorize any physician, medical practitioner, hospital, clinic, insurance company, employer, or other entity that has records or knowledge of me or my health to release to the insurer or its representatives any such information for the purpose of underwriting, rate setting, and claim investigation. I understand that a copy of this authorization shall be as valid as the original.

I consent to release of information to reinsurers and to relevant affiliates as required for underwriting. I understand that the insurer may request additional information and that final acceptance and terms remain subject to underwriting review. I acknowledge receipt of a privacy notice describing how personal information may be used and shared in connection with this request.

By signing above, the applicant certifies under penalty of perjury that the information provided is true and authorizes the insurer to rely upon this request and any attachments as if made in a formal application. The applicant understands that false statements may be subject to civil or criminal penalties where applicable.

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