Insurance PFA Document

Insurance Personal Financial Affidavit (PFA)

Applicant / Insured Information

Applicant Name:

Date of Birth:    Phone:    SSN (last 4):

Policy Details

Policy Type: Life   Disability   Health   Auto   Homeowners   Umbrella

Deductible:    Estimated Annual Premium:    Policy Period: From to

Financial Information — Assets & Income

Job Title:    Gross Monthly Income:

Liabilities & Monthly Obligations

Coverage Selection & Limits

Select the coverage options requested and specify limits where applicable:

Accidental Death Benefit — Limit: $

Waiver of Premium for Total Disability

Beneficiary Designation

Relationship:    Share (%):

Relationship:    Share (%):

Supporting Documentation Checklist

Please indicate documents submitted with this affidavit:

Most recent pay stubs   Bank statements (3 months)   Federal tax returns (2 years)   Property deeds/valuations

Exclusions & Limitations

The following items are not covered unless expressly endorsed: losses arising from fraud, intentional acts, war, nuclear hazard, criminal activity by the insured, pre-existing materially undisclosed financial obligations, and any loss excluded by the policy form. Coverage limits, waiting periods, and sub-limits specified in the issued policy control over any statement in this affidavit.

Declarations, Authorization & Certification

I certify under penalty of perjury that the information provided in this Personal Financial Affidavit is true, complete, and correct to the best of my knowledge. I understand that material misstatements or omissions may result in denial of coverage, rescission of any policy issued, or other lawful remedies. I authorize the insurer, its affiliates, and authorized representatives to verify any financial information contained herein, to obtain credit reports, and to request employment, banking, tax, and public records as necessary to evaluate eligibility and underwriting. I further authorize any person or institution to release such information upon request. This authorization remains effective for the period necessary to evaluate the application and for policy administration.

I agree to promptly notify the insurer in writing of any material change in my financial condition or in the information provided in this affidavit. I understand that coverage is subject to the terms, conditions, exclusions, and limits of the issued policy. I acknowledge that acceptance of this affidavit by the insurer does not constitute binding coverage until a policy is issued in writing and the required premiums are paid.

Additional Information

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