Insurance SPP Forms

INSURANCE SPP FORMS

1. Applicant / Insured Information

Applicant Name:

Date of Birth:    Tax ID / SSN:

2. Policy Details — SPP (Single Premium Payment) Schedule

Policy Number:

Life    Health    Property    Liability    Other:

Payment Method:    Single Premium Payment    Installment    Electronic Transfer    Check

Policy Period: From to

3. Coverage Options & Riders

Select coverage options applicable to this SPP policy (select all that apply):

Basic Liability Coverage    Medical Expense Coverage    Property Damage Coverage

Accidental Death Rider    Waiver of Premium Rider    Critical Illness Rider    Long-Term Care Rider

4. Exclusions and Limitations

The following exclusions apply to this SPP policy unless expressly modified in writing by the insurer:

• Losses caused by war, insurrection, or nuclear hazard.
• Intentional acts, fraudulent or criminal conduct by the insured.
• Pre-existing conditions specifically identified in the policy schedule.
• Claims arising from material misrepresentation or nondisclosure by the applicant.

I acknowledge receipt of the exclusions listed above and understand they form part of the insurance contract.

5. Beneficiary Designation

Primary Beneficiary

Contingent Beneficiary

6. Payment Authorization

Premium Amount to be received by insurer:

If electronic payment is selected, provide account details below or attach bank authorization.

7. Declarations, Authorizations, and Acknowledgements

I certify that the statements and answers on this Insurance SPP Form are true, complete and correctly recorded to the best of my knowledge. I understand that any material misrepresentation or omission may be grounds for denial of coverage, rescission of the policy, or adjustment of benefits in accordance with the terms of the policy.

I authorize the insurer to obtain and verify information necessary to administer the application and policy, including but not limited to underwriting, claims investigation, and premium collection. I consent to release of such information to service providers and reinsurers as required for policy servicing. This authorization remains in effect for the life of the policy unless revoked in writing and does not authorize disclosure for purposes unrelated to the policy.

I understand that payment of a single premium creates coverage only upon acceptance by the insurer and issuance of a policy. Refunds of premium, if any, shall be governed by the policy terms, the insurer’s right-to-cancel provisions, and applicable law.

I affirm the truthfulness of the foregoing declarations and authorize the actions described above.

8. Fraud Warning and Legal Notices

Any person who knowingly presents false information in an application for insurance may be subject to civil or criminal penalties under applicable law. Where required by law, the insurer will provide notice of fraud and suspected fraud to appropriate authorities.

This form, together with the policy schedule and any endorsements, constitutes the entire written application and instruction for the Single Premium Payment policy requested. Changes to the application or policy must be made in writing and signed by an authorized representative of the insurer.

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