Insurance Life Application Report

INSURANCE LIFE APPLICATION REPORT

Applicant / Insured Information

Date of Birth:   Place of Birth:

Telephone:   Email:

Height:   Weight:   Tobacco Use: Yes No

Policy Details

Policy Type: Term Whole Life Universal Variable

Policy Effective Date:   Policy Term / Period:

Coverage Options & Riders

Select additional coverages: Accidental Death Benefit Waiver of Premium Accelerated Death Benefit Child Term Rider

Beneficiary Designation

Relationship:   Allocation Percentage: %

Relationship:   Allocation Percentage: %

Medical and Health Information

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

Heart disease / heart attack Stroke / TIA Diabetes Cancer

Kidney disease Liver disease Mental health / substance use treatment

Are you currently taking prescription medication? Yes No

Exclusions & Notice

The proposed policy will contain standard exclusions, which may include suicide within the contestability period, death resulting from intentionally self-inflicted injury while sane or insane as provided by law, and loss arising from declared or undeclared war or participation in a felony. Coverage of certain hazardous activities, aviation (other than as a fare-paying passenger on a commercial flight), or professional sporting activities may be excluded or rated. The insurer's liability is limited to the terms, conditions and exclusions stated in the issued policy.

By initialing below, the applicant acknowledges receipt and review of the above exclusions and understands that any requested riders, endorsements or special agreements will be stated in the issued policy.

Initials:

Declarations, Authorization and Certification

The undersigned declares that all statements and answers contained in this application are true, complete and correctly recorded to the best of the applicant's knowledge and belief. Any material misstatement or omission of fact may result in denial of coverage or rescission of the policy. The applicant certifies that the consideration of this application is conditioned upon the truthfulness of the statements herein.

The applicant authorizes any licensed physician, medical practitioner, hospital, clinic or other medical or medically-related facility, pharmacy, insurance company, employer, consumer reporting agency or other organization, institution or person that has any records or knowledge of the applicant's health to release such information to the insurer or its reinsurers for underwriting, claims administration and any other lawful purpose. A photocopy or electronic copy of this authorization shall be as valid as the original.

The applicant acknowledges that the insurer will rely on the statements made in this application and any required medical examinations, tests or inspections. The applicant understands that coverage will not become effective unless and until the insurer approves the application and issues the policy, and any required first premium is paid as directed.

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