Insurance SL-2 Form

INSURANCE SL-2 FORM

Applicant / Insured Information

Date of Birth:    Social Security/Tax ID:

Policy Details

Requested Policy Type: Life Health Property Auto Other

Requested Coverage Amount: $    Deductible: $

Annual Premium: $    Policy Period From:    To:

Coverage Selection

Select desired endorsements and limits. Selection is subject to underwriting approval.

Basic Coverage (per policy terms) Accidental Death Benefit Waiver of Premium Critical Illness Rider Hospitalization/Inpatient Benefit

Exclusions and Limitations

The following are standard exclusions under this application unless otherwise expressly agreed in the policy schedule: intentional loss, unlawful acts, self-inflicted injury, loss arising from active military service, losses related to pre-existing medical conditions not disclosed to the insurer, and losses arising from hazardous activities not approved by the insurer. Additional exclusions may be applied after underwriting.

Applicant acknowledges receipt of the exclusions summary and agrees that any coverage issued will be subject to policy terms, conditions, exclusions and endorsements. Applicant confirms all material facts have been disclosed to the best of their knowledge.

I acknowledge I have read and understand the exclusions and limitations above.

Medical and Risk Information

Have you had any of the following in the past 5 years? (Check all that apply)

Hospitalization or surgery Chronic illness (diabetes, heart disease, etc.) Current tobacco or nicotine use Substance abuse treatment None of the above

Height:    Weight:

Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Percentage:

Relationship:    Percentage:

Required Documentation Checklist

Please attach copies of the following. Failure to provide required documentation may delay processing.

Government-issued photo identification Proof of address (utility bill, bank statement) Relevant medical records or physician statement Vehicle registration or property title (if applicable)

Authorization, Certification and Fraud Notice

I certify that the information provided in this application is true, complete and correctly recorded. I understand that any material misrepresentation or omission of fact may be grounds for denial of coverage or rescission of the policy. I authorize the insurer, its agents and representatives to obtain and review any records, including medical and claims records, necessary to evaluate this application and any subsequent claim. A photographic or electronic copy of this authorization shall be as valid as the original.

I understand that coverage is not effective until the insurer issues a policy and receives any required premium, and that any binding of coverage prior to issuance is subject to the insurer's underwriting guidelines. I agree to notify the insurer promptly of any changes in the risk or information provided herein.

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

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