Insurance Life Document

LIFE INSURANCE APPLICATION AND BENEFICIARY DESIGNATION

Applicant / Insured Information

Date of Birth:

Social Security / Tax ID Number:

Policy Details

Term Life Whole Life Universal Life

Policy Period (Effective): From to

Optional Riders and Coverage Selections

Select desired riders (additional premium may apply):

Accelerated Death Benefit (for terminal illness)
Waiver of Premium (disability)
Accidental Death Benefit
Child Term Rider

Exclusions and Limitations

This application is subject to underwriting and the terms and conditions of the policy form issued. Coverage shall be subject to exclusions, including but not limited to: suicide within the period specified in the policy (commonly two years) which may void liability for death benefits; death resulting from insured’s commission of a felonious act; or death arising from declared war or acts of war, except as stated in the policy. Any material misstatement or concealment of facts may render the policy void from its inception as provided by law and policy provisions.

Beneficiary Designation

Primary Beneficiary 1 — Name: Relationship: Share:

Primary Beneficiary 2 — Name: Relationship: Share:

Contingent Beneficiary — Name: Relationship: Share:

If no share percentage is provided, all primary beneficiaries will share equally unless otherwise stated. It is the applicant’s responsibility to ensure percentages total 100% for primary beneficiaries where appropriate.

Medical and Health Information (Summary)

Yes No

Never Current User Former User

Authorization, Representations and Certifications

By signing below, the applicant represents and warrants that all statements contained in this application are true and complete to the best of the applicant’s knowledge and belief. The applicant acknowledges that these statements are relied upon by the insurer in issuing a policy. The applicant understands that any material misrepresentation or omission may result in denial of benefits or rescission of coverage in accordance with policy terms and applicable law.

The applicant authorizes any licensed physician, medical practitioner, hospital, clinic, or other medical professional or facility that has treated the applicant to release to the insurer any medical information or records relating to the applicant’s past or present physical or mental health. This authorization includes disclosure of diagnoses, treatments, prognosis, and testing. A photocopy of this authorization shall be as valid as the original.

The applicant understands that coverage will become effective only if a policy is issued and the full initial premium is accepted by the insurer in accordance with the conditional receipt or policy terms. Premium rates, policy provisions, riders, and any contestability or suicide limitations will be governed by the policy issued.

Fraud Warning: Any person who knowingly and with intent to defraud presents false information in an application for insurance may be guilty of insurance fraud and subject to civil and criminal penalties.

Additional Information / Remarks

Declarations

I declare that I am the person named as the proposed insured and certify that the information provided on this form is full, complete and true. I understand that this application and any representations made herein form the basis for any policy issued. I agree that this application will be attached to and form a part of the policy, if issued.

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