Insurance Plan Application

INSURANCE PLAN APPLICATION

Application Date:    Proposed Effective Date:

1. APPLICANT / INSURED INFORMATION

2. POLICY DETAILS

Policy Type (select all that apply):

Payment Frequency:

3. COVERAGE OPTIONS & RIDERS

Select any additional coverages or riders requested (check all that apply). Selection does not guarantee underwriting acceptance.

4. MEDICAL & HEALTH INFORMATION

Answer each question. Failure to disclose relevant medical history may result in denial or rescission of coverage.

5. BENEFICIARY DESIGNATION

Designate primary and contingent beneficiaries. Percentages must total 100% for each designation class.

6. EXCLUSIONS, LIMITATIONS, AND UNDERWRITING

Coverage is subject to underwriting approval. The insurer may refuse or limit coverage based on medical history, misrepresentation, or incomplete information. The policy will contain specific exclusions and limitations. Typical exclusions may include, but are not limited to, loss arising from:

(a) intentionally self-inflicted injuries or suicide as defined in the policy; (b) losses directly resulting from participation in an illegal act or commission of a felony; (c) war, declared or undeclared, or acts of terrorism where exclusion applies under the policy; (d) loss arising from hazardous activities specifically excluded in the policy; and (e) pre-existing conditions as defined in the policy for which treatment or diagnosis occurred prior to the effective date and are subject to waiting periods or exclusions.

The insurer reserves the right to require medical examinations, obtain medical records, and verify any statements made in this application. Fraud, intentional misrepresentation, or material omission may render this application void and permit rescission of coverage.

7. AUTHORIZATION AND CERTIFICATION

I certify that the statements and answers in this application are complete and true to the best of my knowledge and belief. I understand that these statements will be relied upon by the insurer in determining eligibility for coverage and the terms of any policy issued. I authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically-related facility, insurance company, or consumer reporting agency to release to the insurer any medical or other information relevant to this application for insurance.

I understand that no coverage is in force until the insurer issues an acceptance and the first premium is paid, except where a conditional receipt or temporary coverage provision is expressly provided and issued in writing. I acknowledge that I have read and understand the exclusions and limitations set forth above.

8. PRIVACY AND USE OF INFORMATION

Information collected in this application will be used to evaluate eligibility, administer the policy, and investigate claims. The insurer may disclose information to reinsurers, administrators, auditors, and other parties as permitted by law. The applicant has certain rights to request access to and correction of personal information held by the insurer; such requests must be made in writing to the insurer's privacy or customer service department.

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