Insurance LifeGAP Policy Form

Insurance LifeGAP Policy Form

Applicant / Insured Information

Date of Birth:    Social Security / Tax ID:

Policy Details

Requested Policy Number (if replacing):

Term Coverage    Whole Life    Universal Life

Policy Period Start:    End:

Coverage Options and Riders

The applicant requests the following additional coverages (check all applicable). Applicant acknowledges additional premium may apply.

Accidental Death Benefit Rider
Accelerated Benefit for Terminal Illness
Children's Term Rider
Waiver of Premium for Disability
Return of Premium Option

Exclusions and Limitations

Unless otherwise provided in the policy contract, benefits will not be paid for loss resulting from:

• Intentionally self-inflicted injury or suicide within the contestable period;
• Losses arising from active participation in a felony, riot, or insurrection;
• Death sustained while under the influence of illegal drugs, or adverse effects from voluntary misuse of alcohol;
• War, declared or undeclared, or service in the armed forces; and
• Any material misrepresentation in the application for coverage as described in the contestability clause below.

Beneficiary Designation

Primary Beneficiary 1

Primary Beneficiary 2 (optional)

Premium Payment and Billing

Monthly    Quarterly    Annual

ACH / Bank Draft    Credit / Debit Card    Bill Me / Invoice

Grace Period: A grace period of 31 days from the premium due date applies unless otherwise stated in the policy. Failure to pay premium within the grace period may result in termination of coverage.

Claims and Proof of Loss

Date of Loss / Death:

Documentation Checklist: Please attach death certificate, primary policy payout documentation, outstanding mortgage or loan balance statements if LifeGAP claim, and any medical records reasonably necessary to adjudicate the claim.

Representations, Certification and Authorization

The applicant certifies that all statements in this application are true and complete to the best of the applicant's knowledge. The applicant acknowledges that any material misrepresentation or omission may result in denial of benefits, rescission of coverage, or other remedies permitted by law. The applicant further understands that the insurer may, within the first two years following the effective date of coverage, investigate medical history and information provided and may void the policy for material misrepresentations discovered during that period.

Authorization: The applicant authorizes any physician, medical practitioner, hospital, clinic, facility, or other medically related facility to provide to the insurer any records, reports, and information related to medical history, treatment, or prognosis. A photocopy or electronic copy of this authorization shall be as valid as the original.

Assignment of Proceeds: Unless otherwise indicated in the beneficiary designation above, proceeds payable under the policy shall be paid to the designated beneficiary or beneficiaries. The insurer is not responsible for determining the validity of any assignment beyond its receipt and recording of a written assignment in its files.

Important Notices

Contestability: Except for fraud, no statement made by the insured in the application shall be used to void the policy or deny a claim after the policy has been in force for two years from its effective date. Fraud or intentional misrepresentation may void coverage from inception.

Suicide Exclusion: If suicide, while sane or insane, occurs within two years from the effective date of coverage, the policy limits recovery to the return of premiums paid, subject to applicable law.

Cancellation: The insurer may cancel coverage in accordance with the policy terms and applicable law. The applicant may cancel during any free look period as stated in the policy contract and may request termination of coverage at any time.

Acknowledgment

By signing below, the applicant declares under penalty of perjury that the information provided in this form is complete and accurate, that the applicant has read and understood the foregoing statements, and that the applicant agrees to the terms and conditions set forth in this application and the issued policy.

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