Insurance Life Application Form

INSURANCE LIFE APPLICATION FORM

Applicant / Insured Information

Policy Selection and Coverage

Type of Policy (check all that apply): Term Whole Life Universal Life Variable Life

Riders and Additional Coverages: Accidental Death Benefit Waiver of Premium Child Rider Chronic/Critical Illness

Premium & Payment

Automatic Bank Draft Credit/Debit Card Check

Beneficiary Designation

Primary Beneficiary 1: Relationship: Share %: %

Primary Beneficiary 2: Relationship: Share %: %

Contingent Beneficiary(ies):

Medical History & Health Information

Please answer the following for the proposed insured. If yes to any, provide details in the box below.

1. Have you been diagnosed with or treated for heart disease, stroke, cancer, diabetes, or AIDS? Yes No

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

3. Have you been hospitalized or had surgery in the past 5 years? Yes No

Exclusions, Limitations and Important Notices

By signing this application the applicant acknowledges that coverage will be subject to the policy terms, exclusions and limitations. The insurer may deny or limit benefits for death or injury resulting from suicide within the contestability period, acts of war (declared or undeclared), participation in felonies, or engagement in hazardous pursuits if such facts are material and not disclosed. Statements made in this application may be used to contest the policy for material misrepresentations during the contestability period specified in the policy.

Authorization and Declarations

I hereby declare that the information provided in this application is true, complete and correctly recorded to the best of my knowledge. I understand that this application, any medical examinations, and any required reports will form the basis of any policy issued. I understand that coverage will not become effective until the application is approved by the insurer and the first premium is accepted in accordance with the insurer's acceptance rules.

I authorize any licensed physician, medical practitioner, hospital, clinic, insurance or reinsuring company, the Medical Information Bureau and other organizations or persons that have any records or knowledge of me or my health to release to the insurer or its representatives any such information. I authorize a copy of this authorization to be used in place of the original.

By indicating consent below I agree to receive policy documents, notices and communications electronically if permitted by law. Consent: Yes No

Agent / Broker Information (if applicable)

Acknowledgement and Signature

I understand that any person who, with intent to defraud or knowing that he or she is facilitating a fraud against the insurer, submits an application or files a claim containing a materially false, incomplete or misleading statement may be guilty of insurance fraud and subject to civil and criminal penalties under applicable law.

I certify that I have read and understand the statements and authorizations contained in this application. I acknowledge that I received any disclosures required by law in connection with this application.

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