Insurance Mortality Application

Insurance Mortality Application

Applicant / Insured Information

Date of birth:    Place of birth:

Phone:    Email:

Policy Details

Proposed policy number:    Policy type: Term Whole Life Universal

Premium mode: Annual Monthly Single Premium

Policy period: Effective date through Expiration date

Coverage Options & Riders

Select applicable riders (check all that apply):

Accidental Death Benefit Rider    Accidental Dismemberment Rider

Waiver of Premium Rider    Child Term Rider

Exclusions & Limitations

The following exclusions are standard to this application and, if applicable, to the policy issued: death by suicide within the contestability period, death resulting from participation in unlawful acts, death caused by active military service in a declared war, and losses resulting from participation in professional hazardous sports. Any additional exclusions endorsed to the policy will be set forth in the policy terms.

Applicant acknowledges receipt and understanding of the exclusions above:

Medical & Health History

Are you currently using tobacco, nicotine products, or nicotine replacement therapies? Yes No

Have you been diagnosed with or treated for any of the following in the past 10 years? (Check all that apply)

Heart disease or attack    Stroke    Cancer

Diabetes    Kidney disorder    Other (provide details below)

Current height:    Current weight:

Beneficiary Designation

Primary beneficiary

Contingent beneficiary

Declaration, Authorization & Certification

I certify that the statements and answers in this application are true, complete and correctly recorded to the best of my knowledge and belief. I understand that any misrepresentation or omission of a material fact made with intent to defraud or which materially affects the risk may render any policy issued voidable and may constitute grounds for denial of a claim.

I authorize any physician, medical practitioner, hospital, clinic, insurance company, employer, or other person or institution that has any records or knowledge of me to provide such information to the insurer, its reinsurers and its authorized representative for the purpose of underwriting, policy administration, or claim determination. A copy of this authorization shall be as valid as the original. I understand that medical information obtained with this authorization will be used by the insurer to evaluate the application and may be disclosed to reinsurers or persons performing business or legal services for the insurer.

I acknowledge that the insurer may require an examination by its medical representative, collection of laboratory specimens, or additional information. I understand that coverage will not be effective until the insurer accepts the application and the required premium is paid, and any acceptance may be subject to terms, underwriting requirements and exclusions.

I understand and agree that any policy issued on the basis of this application will contain a contestability provision and a suicide provision as permitted under applicable law. I hereby certify that I have read and understand the statements contained in this application and that they are complete and true.

Applicant attests by checking the box below that all responses above are true and complete:

Authorization for Electronic Delivery and Premium Transactions

By signing below, the applicant consents to receive policy documents and notices electronically where permitted by law, and authorizes premium withdrawals or billings to the account or billing method provided at application, subject to policy terms. The applicant may revoke electronic delivery consent by written notice to the insurer in accordance with the policy.

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