Insurance Membership Application

Insurance Membership Application

Applicant Information

Date of Birth:    Social Security Number or Tax ID:

Policy Details

Policy Type: Individual Family Group

Proposed Policy Period: From to

Coverage Selection

Please indicate coverages to be included in membership (select all that apply):

Personal Liability
Medical Payments
Theft
Fire and Smoke Damage
Flood (subject to separate underwriting)
Accidental Death Benefit
Disability Income
Critical Illness

Exclusions and Limitations

The policy for which membership is sought will include exclusions and limitations. Standard exclusions include, but are not limited to: losses arising from intentional or criminal acts by the insured; war, insurrection or nuclear hazards; willful noncompliance with material statutory or regulatory obligations; losses arising from professional services unless specifically endorsed; and pre-existing conditions where applicable. Coverage for specific perils may be subject to additional endorsements, sublimits and waiting periods.

Have you had any insurance claims, losses, cancellations, or non-renewals in the past five (5) years? Yes No

Beneficiary Designation

Designate beneficiary(ies) for benefits payable under the policy. Percentages must total 100%.

Relationship:    Percentage:

Relationship:    Percentage:

Payment Authorization

Preferred Payment Method: Credit Card Bank Debit (ACH) Check

By providing the foregoing information and signing below, Applicant authorizes the insurer or its administrator to initiate recurring premium charges, to the extent permitted under the applicable policy and law. Applicant understands that acceptance of payment does not constitute issuance of coverage until a policy is issued and all underwriting conditions are satisfied.

Declarations, Authorizations, and Certifications

I certify that the statements and answers in this application are true, complete and correctly recorded to the best of my knowledge. I understand that any material misstatement, omission or concealment of fact may be the basis for denial of benefits or rescission of coverage. I authorize the insurer and its representatives to obtain and verify information from any source deemed necessary, including but not limited to past insurers, employers, medical providers, and consumer reporting agencies as needed for underwriting and claims administration. I authorize release of information to insurers, reinsurers, and service providers for underwriting, claim handling and fraud control. A photographic or electronic copy of this authorization shall be as valid as the original.

Applicant agrees to promptly notify the insurer of any change in material facts, including but not limited to change of residence, occupation, or health status, while this application is pending. Coverage is subject to the terms, conditions and exclusions of the policy and any endorsements. No agent, broker, or field representative may alter, modify or waive any provision of the policy or bind coverage except as expressly set forth in a written binder issued by the insurer.

Fraud Notice: Any person who knowingly presents a false or fraudulent claim or application for insurance may be guilty of a criminal act and subject to penalties under applicable law, including fines and imprisonment.

Acknowledgement

By signing below, Applicant acknowledges receipt of this application, attests to the truthfulness of the information provided, and consents to the insurance company’s collection, use and disclosure of personal information as necessary to process this application and administer any resulting policy.

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