Insurance Mortality & Medical Application

INSURANCE MORTALITY & MEDICAL APPLICATION

Client Name:    Date of Birth:    SSN/Tax ID:

Applicant Information

Tobacco/Nicotine Use: Yes No    If yes, last use and frequency:

Alcohol Use: Yes No    Frequency:

Policy Details

Requested Policy Type: Term Whole Life Universal Variable

Policy Period: From to

Optional Riders and Coverage

Accelerated Death Benefit Waiver of Premium Accidental Death Benefit Disability Income Rider

Medical History

In the space below, indicate any medical conditions, diagnoses, or treatments. Check all that apply and provide dates and details in the associated text areas.

Heart disease or coronary artery disease

Cancer (specify type)

Diabetes Hypertension Stroke

Are you currently pregnant? Yes No    If yes, expected delivery date:

Have you ever been declined, postponed, rated, or had a policy cancelled by any insurer? Yes No

Medical Tests and Diagnostics

ECG within last 5 years: Yes No    Date:

Chest X-ray within last 5 years: Yes No    Date:

Laboratory tests (blood/urine) within last 5 years: Yes No    Date:

Beneficiary Designation

Primary Beneficiary Name:    Relationship:    Percentage:

Contingent Beneficiary Name:    Relationship:    Percentage:

Exclusions, Limitations & Important Notices

The insurer may refuse benefits, rescind coverage, or deny claims where material misrepresentation, omission, or fraud is discovered. Coverage will not include death or loss resulting from engaging in illegal activities, participation in wartime operations, or specified hazardous pursuits when such exclusion is plainly stated in the policy. Suicide within the contestability period and losses arising from material non-disclosure of medical conditions are subject to the policy's contestability and exclusion provisions.

The answers and statements in this application are the basis for any policy issued. Any material misstatement or omission may render the policy voidable for the contestability period provided in the policy. The insurer reserves the right to require additional examinations, testing, or records before issuance.

Declarations and Authorization

I hereby declare that the foregoing statements and answers are true and complete to the best of my knowledge and belief. I understand that this application, together with any medical examination and medical records, will form the basis of the insurance contract.

I authorize any physician, medical practitioner, hospital, clinic, laboratory, or other medically-related facility that has provided medical treatment, testing, or examinations to me to release to the insurer or its representatives any information from my medical records necessary to evaluate this application for insurance. I further authorize the insurer to obtain consumer reports and investigative consumer reports for underwriting purposes where permitted by law.

I understand that a photocopy or electronic reproduction of this authorization is as valid as the original. I agree that the insurer may request a medical examination, tests (including blood and urine), and other diagnostic procedures as part of underwriting, and I authorize such tests.

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