Insurance Policy NY Life

INSURANCE POLICY NY LIFE

Policy Identification

Policy Number:    Issuer:

Effective Date:    Expiration Date:

Applicant / Insured Information

Policy Details & Premium

Policy Type:

Coverage Amount: $    Deductible: $

Payment Frequency: Monthly Quarterly Annual

Coverage Selections and Riders

Select coverages applicable to this policy. Limits shown are maximums subject to insured underwriting and policy terms.

Death Benefit
Accidental Death Rider
Terminal Illness Accelerated Benefit
Waiver of Premium for Disability
Chronic Illness Rider

Exclusions and Limitations

The following exclusions apply unless otherwise expressly endorsed to this policy. The Company will not be liable for loss or benefit payments arising from any of the following:

• Suicide within the period specified in the policy; benefits will be limited as described in the Suicide provision.
• Loss arising from participation in criminal activity, illegal acts, or the commission of a felony.
• Loss or claim resulting from active participation in war, declared or undeclared hostilities, or insurrection.
• Loss resulting from intentionally self-inflicted injury or attempted self-harm while sane or insane.
• Pre-existing conditions as defined in the policy for which medical advice, diagnosis, care or treatment was recommended or received within the pre-existing period prior to the effective date.

Applicant Acknowledgement: I acknowledge that I have received, read, and understood the exclusions and limitations set forth above. Acknowledged

Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Percentage:

Contingent Beneficiary Name:

Relationship:    Percentage:

Claims Procedure (When a Loss Occurs)

Date of Loss:

Required documentation at time of claim (check each submitted):
Death certificate (if applicable)
Proof of loss / medical records
Police or incident report (if applicable)
Itemized billing, receipts or estimates

Declarations and Conditions

By signing below, the Applicant certifies that the statements and answers herein are complete, true and correctly recorded to the best of the Applicant's knowledge and belief. Any material misrepresentation or omission in this application may render this policy voidable at the Company's option and may bar recovery of benefits to the extent permitted by law.

Incontestability: After two years from the date of issue of this policy, no misstatement of age or medical history, except fraud, shall be used to contest coverage or deny claims except as permitted by applicable law. This provision does not apply to the non-payment of premiums.

Grace Period and Non-Payment: A grace period will be provided for the payment of each premium in accordance with the terms set forth in the policy schedule. Failure to pay premium by the end of the grace period may result in termination of coverage as specified in the policy.

Assignment: This policy may be assigned in whole or in part by written instrument submitted to the Company. The Company assumes no responsibility for the validity or sufficiency of any assignment or endorsement.

Reinstatement: If coverage lapses for nonpayment, reinstatement will be subject to the Company's standard underwriting, receipt of proof of insurability acceptable to the Company, and payment of any past due premiums as set forth in the policy provisions.

Governing Law: This policy shall be governed by and construed in accordance with the laws of the State of New York where applicable in determining rights and obligations under the policy.

Authorization and Consent

I authorize any physician, medical practitioner, hospital, clinic, insurance company, employer, or other entity to release to the Company medical and non-medical information necessary to underwrite or administer this policy and any claim. A photocopy of this authorization shall be as valid as the original.

Acknowledgement

I understand that issuance of the policy is conditioned upon acceptance of this application and receipt of the initial premium. I understand the policy will include specific contract terms, riders, exclusions and endorsements which constitute the full agreement between the Company and the Insured.

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