Insurance Life Packet

Insurance Life Packet

This Insurance Life Packet collects information necessary to underwrite, issue, and administer an individual life insurance policy. All questions must be answered fully and truthfully. Material misrepresentation, omission, or fraud may result in denial of benefits, policy rescission, or adjustment of coverage consistent with the policy terms and applicable law.

Applicant / Insured Information

Full legal name:

Policy Details

Requested policy type: Term Whole Life Universal Life Variable Life

Policy period: Effective date to

Beneficiary Designation

Primary beneficiaries (designate percentages that total 100%):

Contingent beneficiary(ies):

Coverage Options and Riders

Select additional coverage options requested (each rider is subject to eligibility, underwriting and additional premium as applicable):

Waiver of Premium (disability)
Accidental Death Benefit
Accelerated Death Benefit / Terminal Illness
Guaranteed Insurability Rider
Child Term Rider

Medical History & Risk Assessment

Please answer the following. Mark all that apply. Additional medical information may be requested.

Smoker/Tobacco use: Yes No

Height: Weight:

In the past 10 years, have you been diagnosed with or treated for any of the following? Check each that apply:

Cancer or tumor
Heart disease, heart attack, stroke
Diabetes
Mental health disorder or counseling
Major surgery or hospitalization
Alcohol or drug treatment
Hazardous occupation or avocational activities (e.g., aviation, scuba diving)

Exclusions, Contestability and Limitations

The policy will contain specific exclusions and limitations. Typical provisions include, but are not limited to:

1. Suicide provision: If the insured dies by suicide within the contestability period, the company may rescind or limit benefits as provided in the policy.
2. Illegal acts or participation in felony: Death resulting from commission of a felony may be excluded.
3. War or act of war: Loss from declared or undeclared war or hostile acts may be limited or excluded.
4. Material misrepresentation: Misstatements or omissions in this application may lead to rescission, denial, or adjustment of coverage pursuant to the policy contestability provisions.

Authorization and Release

By signing below the applicant authorizes any physician, medical professional, hospital, clinic, medical facility, pharmacy benefit manager, insurer, employer, consumer reporting agency, or other organization or person that has medical or non-medical information about the applicant to disclose such information to the insurer and its legal representatives for purposes of policy underwriting, claims determination, policy administration, and reinsurance. This authorization includes medical records, prescription history, motor vehicle records, and financial information when relevant to underwriting.

The applicant further authorizes the insurer to obtain an investigative consumer report and to disclose necessary information to reinsurers. A photographic or electronic copy of this authorization shall be as valid as the original.

Declarations & Fraud Notice

I certify that the statements and answers in this packet are true and complete to the best of my knowledge and belief. I understand that these statements will be relied upon to determine insurability and policy terms. I understand that intentional misrepresentation or fraud may subject me to criminal penalties and give the insurer grounds to contest or rescind coverage in accordance with the policy.

Applicant acknowledgement: I certify the information provided is complete and accurate.

Document Certification

I authorize the insurer and its representatives to rely upon the statements made in this packet for underwriting and issuance of the requested policy. I understand that additional evidence (medical examination, lab tests, financial documents) may be required and that issuance of a policy is subject to underwriting approval and receipt of required premiums.

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