Insurance Life Form

INSURANCE LIFE FORM

Applicant Information

Date of Birth:    Social Security Number:

Phone:    Email:

Are you a tobacco user? Yes No    Have you used nicotine products in the past 12 months? Yes No

Policy Details

Policy Type: Term Life Whole Life Universal Life Variable Life

Premium Amount:    Payment Mode: Annual Monthly Quarterly

Policy Effective Date:    Policy Term (if applicable):

Coverage Options and Riders

Select additional coverage/riders to be attached to the policy (initial each selected rider where required):

Accidental Death Benefit Rider    Waiver of Premium Rider    Children's Term Rider

Medical Information

Height:    Weight:

Date of Last Medical Exam:    Primary Care Physician:

Are you currently receiving treatment, prescribed medication, or counseling? Yes No

Exclusions, Limitations, and Acknowledgments

The applicant acknowledges and agrees that the policy shall not cover loss resulting from:

• Suicide within the initial period specified in the policy;
• Loss sustained while committing or attempting to commit a felony or engaging in illegal acts;
• War, declared or undeclared, or active participation in a warlike operation;
• Self-inflicted injuries while sane or insane subject to applicable law;
• Specified hazardous activities excluded by endorsement when a premium reduction or surcharge is applied.

Applicant initial to acknowledge review of exclusions:

Beneficiary Designation

Primary Beneficiary Name:    Relationship:    % Share:

Contingent Beneficiary Name:    Relationship:    % Share:

The undersigned understands that the percentages shown above should total 100% for primary beneficiaries. If no designation is valid at the time of claim, proceeds shall be payable in accordance with the policy terms.

Declaration and Authorization

I, the Applicant, declare that the statements and answers contained in this form are true and complete to the best of my knowledge and belief. I understand that any material misstatement or omission may void coverage or result in denial of a claim under the terms of the policy.

I authorize any licensed physician, medical practitioner, hospital, clinic, pharmacy, insurance company, consumer reporting agency, employer, or other organization or person that has any records or knowledge of me or my health to disclose such information to the insurer, its representatives, and reinsurers for the purpose of underwriting, claim determination, or as required by law. A copy of this authorization shall be as valid as the original.

I understand and agree that this application, together with any required medical examinations and the policy issued, shall constitute the entire contract. I further understand that no agent has authority to alter the terms of the policy, waive any of the insurer's rights, or accept risks on behalf of the insurer except as set forth in a policy issued by the insurer.

I acknowledge receipt of the pre-notice of replacement (if applicable) and certify that I have responded truthfully to all questions. I understand that acceptance of coverage is subject to the insurer's underwriting review and issuance of a policy.

Any person who knowingly presents false information in an application for insurance may be subject to civil and criminal penalties, including denial of benefits or rescission of the policy, in accordance with applicable law.

Agent / Producer (if applicable)

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