Insurance Life Application Packet

Insurance Life Application Packet

This Insurance Life Application Packet (the "Application") is submitted by the Applicant to request issuance of a life insurance policy subject to the insurer's underwriting, acceptance and policy provisions. Completion of this Application, truthful disclosure, and execution of the Authorization and Certification below are required for consideration of coverage.

1. Applicant Information

Date of Birth:    Social Security Number / Tax ID:

2. Policy Request and Coverage

Requested Policy Type: Term Whole Life Universal Life Variable Life

Premium Amount:    Premium Frequency: Monthly Quarterly Annual

3. Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Share Percentage:

Beneficiary designation will control distribution of proceeds unless otherwise provided by a later valid written designation accepted by the insurer. Applicant represents that the percentages total 100% and understands that failure to designate valid beneficiaries may result in distribution under the policy's terms.

4. Medical and Health Information

Height:    Weight:

Do you use tobacco or nicotine products? Yes No

5. Underwriting and Attachments

Submitted with this Application (check all that apply):

Medical examination report
Laboratory results
Copy of prior life insurance policy
Financial statements / income verification

6. Exclusions, Limitations and Notices

The policy, if issued, will contain exclusions and limitations customary to life insurance policies. Common exclusions may include death resulting from intentionally self-inflicted injury within an initial contestability period, death while committing a felony, and losses caused by acts of war as defined in the policy. Applicant understands that coverage is subject to the insurer's underwriting and to specific provisions, riders, and endorsements included in any issued policy.

Has the applicant ever been declined, postponed, rated, or had coverage modified by any insurer? Yes No

7. Authorization, Certification and Acknowledgment

Authorization: I, the Applicant, authorize any licensed physician, medical practitioner, hospital, clinic, medical facility, pharmacy benefit manager, insurer or other healthcare provider, and any consumer reporting agency or MIB-type organization to furnish to the insurer or its reinsurers any and all information concerning my physical and mental health, medical history, treatments, consultations, prescriptions, and drug and alcohol abuse records. I authorize the insurer to obtain motor vehicle records, hazardous pursuits information, financial records for suitability and income verification, and investigative consumer reports where permitted by law.

Certification: I certify that the answers and statements in this Application are true and complete to the best of my knowledge and belief. I understand that any material misrepresentation made in this Application may be grounds for rescission or denial of benefits consistent with the policy terms and applicable law. I further understand that coverage, if issued, will be effective only upon delivery of the policy and payment of the first premium while the information remains true and complete.

I acknowledge receipt of any required disclosures and authorize electronic or paper delivery of policy documents where permitted. I agree that a photographic or electronic copy of this Authorization shall be as valid as the original.

8. Agent / Producer Information

9. Important Notices

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

Contestability: Statements in this Application may be contested in accordance with the policy's contestability provision. Coverage may be rescinded and benefits denied if material misrepresentations or omissions are discovered during the contestability period.

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