Insurance Life Application

Insurance Life Application

Applicant / Insured Information

Insured Full Legal Name:

Date of Birth:    Social Security Number:

Gender:    Marital Status:

Policy and Coverage Details

Intended Policy Type:   Term Life   Whole Life   Universal Life

Policy Effective Date:    Requested Term / Period:

Optional Riders and Coverage Selections

Select riders to be included with this application:

Accidental Death Benefit Rider
Waiver of Premium for Disability
Child Term Rider
Guaranteed Insurability Option

Beneficiary Designation

Primary Beneficiary 1 - Name: Relationship: Percentage:

Contingent Beneficiary 1 - Name: Relationship: Percentage:

Total allocation of primary beneficiaries must equal 100%. If no contingent beneficiary is named, proceeds will be paid according to the policy provisions.

Medical and Health History

Height:    Weight:

In the past 10 years, have you been diagnosed with or treated for any of the following? (Check all that apply)

Heart disease, heart attack or stroke
Cancer or tumor
Diabetes or endocrine disorder
Depression, anxiety, or other mental health condition
Kidney or liver disease
Other (specify below)

Do you use tobacco or nicotine products? Yes   If yes, date of last use:

Exclusions, Limitations and Important Notices

The proposed policy will contain exclusions and limitations, including but not limited to:

1. Fraud or intentional misrepresentation in this application may render the policy voidable. The insurer may rescind coverage if material facts are misrepresented.
2. A contestability period applies during which the insurer may investigate statements on this application; material misstatements may be relied upon to rescind or deny claims.
3. Suicide within the policy suicide exclusion period will be handled in accordance with the policy provisions.
4. Death resulting from acts of war, participation in criminal activity, or deliberate exposure to hazardous conditions may be excluded from coverage.

Authorization and Applicant Certification

I certify that the statements and answers contained in this application are complete and true to the best of my knowledge and belief. I understand that any materially false, incomplete, or misleading statement may be used to deny benefits or rescind the policy in accordance with the policy terms and applicable law.

I authorize any medical practitioner, hospital, clinic, laboratory, medical facility, insurance company, consumer reporting agency, and the Medical Information Bureau to release medical and other information about me to the insurer, its reinsurers, its authorized agents, and service providers for the purpose of underwriting, policy issuance, claims administration, or fraud detection. A photographic or fax copy of this authorization shall be as valid as the original.

I understand that the insurer may request additional information, require a medical examination or tests (which may include blood tests, urine tests, and tests for infectious diseases), and obtain my medical records as necessary to evaluate this application. I consent to such examinations and testing as required.

By signing below I acknowledge that I have read and understand the statements, authorizations, and notices contained in this application. I request the insurance applied for and agree that this application and any required supplements will form the basis for any policy issued.

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