Insurance LifeGAP Document

INSURANCE LIFEGAP DOCUMENT

Applicant / Insured Information

Full Legal Name:

Policy Details

Policy Number (if assigned):

LifeGAP Primary Coverage (bridging benefit to cover premium shortfall)
Accidental Death Benefit Rider
Terminal Illness Accelerated Benefit
Waiver of Premium for Total Disability
Child Term Rider

Policy Period (Start - End): Start End

Coverage Specifics and Limits

LifeGAP Benefit Description: The LifeGAP benefit provides a limited, supplemental payment to cover the difference between the insured's existing life insurance premium obligation and the insured's ability to pay, subject to the terms, limits and exclusions of this document. Benefit payments are limited to the lesser of documented premium shortfall or the Coverage Amount.

Risk & Health Declarations

Has the proposed insured used tobacco or nicotine products within the past 12 months? Yes No

Within the past 5 years, has the proposed insured been diagnosed with or treated for any of the following conditions: heart disease, cancer, stroke, chronic lung disease, or diabetes?
Yes No

Beneficiary Designation

Primary Beneficiary 1 — Name: Relationship: Percentage:

Contingent Beneficiary — Name: Relationship: Percentage:

Exclusions & Limitations

Standard exclusions apply to LifeGAP coverage. Coverage will not be provided for loss or claim arising directly or indirectly from: intentionally self-inflicted injury, suicide within contestability period, war or acts of war, participation in felony or illegal activity, proven material misrepresentation on the application, or any pre-existing condition not disclosed as required by this document. Additional exclusions specific to riders apply as detailed below.

Claims, Documentation & Proof

When a claim is submitted under LifeGAP, the claimant must provide sufficient documentation to substantiate a premium shortfall, including: copies of invoices or premium notices, proof of insured's premium obligation, evidence of inability to pay premiums (if applicable), and any medical or death certificates required for the benefit claimed. The insurer may request additional documentation and reasonable proof of loss.

Declarations, Authorizations & Certifications

I, the undersigned, represent and warrant that the information provided in this Insurance LifeGAP Document is true, complete and correct to the best of my knowledge and belief. I acknowledge that material misrepresentation or omission of relevant facts may void coverage, limit benefits, or render coverage unenforceable.

I authorize the insurer, its agents and representatives to obtain medical, financial and other records necessary to evaluate this application and any subsequent claims. I further authorize any licensed physician, hospital, clinic, employer or consumer reporting agency to release such records upon request. A copy of this authorization shall be as valid as the original.

I acknowledge the existence of a contestability period during which the insurer may contest the validity of coverage based on misrepresentation. I understand this document may be cancelled in accordance with the cancellation provisions of the policy and that premium payment is required to maintain active coverage.

Fraud Warning: Any person who knowingly presents false or fraudulent information in an application for insurance or in the filing of a claim may be guilty of a crime and subject to penalties under applicable law. By signing below, I certify under penalty of perjury that the foregoing statements are true.

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