Insurance No Medical Questions

INSURANCE — NO MEDICAL QUESTIONS APPLICATION

Complete this application to request coverage under a policy that issues without medical underwriting. Submission of this application does not guarantee coverage; coverage becomes effective only upon insurer acceptance and receipt of initial premium in accordance with the terms below. All answers must be true and complete to the best of the applicant's knowledge.

Applicant / Insured Information

Policy Selection & Premium

Select the product for which you are applying and indicate the desired coverage and payment terms. The insurer may limit issued coverage based on age, residency, or other non-medical eligibility criteria.

Guaranteed Issue Life Insurance
Limited Benefit Life Insurance
Accident-Only Indemnity

Coverage Options

Select the coverages to be included in the policy. Some coverages may be subject to additional limits or waiting periods as described in the Exclusions and Limitations section.

Accidental Death Benefit
Accidental Dismemberment Benefit
Hospital Indemnity (per day benefit)
Waiver of Premium for Total Disability
Other Rider(s):

Exclusions, Limitations, and Waiting Periods

The following exclusions and limitations apply unless specifically modified by endorsement: (1) No benefits for loss caused by acts of war or declared military service; (2) Losses arising from attempted suicide or self-inflicted injury within the first 24 months from the policy effective date will be excluded and premiums refunded subject to policy terms; (3) Losses resulting from participation in illegal activity or criminal acts are excluded; (4) Benefits for pre-existing conditions may be limited or excluded for a specified period not to exceed 24 months from the policy effective date; (5) Intoxication or impairment due to drugs or alcohol at the time of loss may void coverage for that loss.

I acknowledge that I have read and understand the exclusions and limitations listed above:

Beneficiary Designation

Primary Beneficiary Name: Relationship: Percentage:

Contingent Beneficiary Name: Relationship: Percentage:

Payment Authorization

Payment Frequency: Monthly Quarterly Annual

Payment Method: Credit/Debit Card Bank Draft (ACH) Check

Declaration, Authorization, and Certification

By signing below, I certify under penalty of fraud that the statements and answers contained in this application are true, complete, and correctly recorded. I understand that no medical examination is requested or required for this application and that acceptance of coverage will be based on the answers provided herein and on applicable non-medical eligibility criteria. I understand that any material misrepresentation or omission of fact may result in denial of benefits, rescission of the policy, or adjustment of coverage in accordance with the policy terms.

I authorize the insurer and its representatives to obtain and verify information necessary to underwrite this application, including but not limited to consumer reports, motor vehicle records, and publicly available records. I authorize any person or organization that has records or knowledge of me to release such information to the insurer. A copy of this authorization shall be as valid as the original.

I acknowledge and agree that the insurer's acceptance of this application may be conditioned upon receipt of initial premium. If coverage is not accepted, any premium paid will be returned in accordance with the insurer's refund practice. I understand that after acceptance, the policy may be contested for misrepresentation during the contestability period set forth in the policy.

Applicant consents to receive policy documents, billing notices, and communications electronically where permitted by law:

Fraud Warning: Where applicable by law, any person who knowingly presents false information in an application for insurance may be guilty of insurance fraud and subject to civil or criminal penalties.

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