Insurance Statement of Insurability

INSURANCE STATEMENT OF INSURABILITY

Applicant Information

Applicant Name:

Date of Birth:    Place of Birth (City, State):

Social Security Number (last 4 digits):    Telephone:    Email:

Policy and Coverage Requested

Requested Coverage Amount: $    Requested Deductible: $

Proposed Policy Period From: To:

Coverage Selections

Select coverage components being applied for Life Insurance
Disability Income
Critical Illness
Accidental Death Benefit
Long-Term Care Rider
Other:

Health and Medical History

Height:    Weight:    Current Smoker/Tobacco Use: Current   Former   Never

Heart disease, heart attack, angina, or stroke
Cancer or malignant tumor
Diabetes or endocrine disorder
Mental health or substance abuse disorder
Kidney, liver or gastrointestinal disease
Respiratory disease (including COPD/asthma)
Other serious medical condition:

Occupational and Hazardous Activities

Occupation:

Aviation (other than fare-paying passenger)
Commercial marine or offshore work
Rock climbing, racing, mountaineering
Other hazardous avocation:

Beneficiary Designation

Exclusions, Notices and Authorizations

The insurer may deny, limit or rescind coverage for misrepresentations or omissions material to the risk. I understand that coverage applied for will be subject to the insurer's underwriting and approval, and that any benefits will be paid only in accordance with the terms and conditions of the policy issued.

Authorization: I authorize any licensed physician, medical practitioner, hospital, clinic, pharmacy benefit manager, insurer, consumer reporting agency, and other individuals or organizations to disclose to the insurer or its reinsurers any medical or other information about me that relates to the underwriting of insurance. I further authorize the insurer to obtain medical records and investigative consumer reports and to disclose information to reinsurers and other insurers as needed for underwriting and claims administration.

A photocopy or electronic reproduction of this authorization shall be as valid as the original. This authorization shall remain valid for a period necessary to complete underwriting and claim evaluation, and for any period required by applicable law.

Fraud Warning: Any person who knowingly presents false information or omits material facts in an application for insurance may be subject to criminal or civil penalties, including but not limited to fines, imprisonment, and denial of benefits.

Declaration and Certification

By signing below I certify that the statements and answers in this Statement of Insurability are full, complete and true to the best of my knowledge and belief. I understand that any material misrepresentation or omission may result in denial of coverage, rescission of coverage, or adjustment of benefits. I agree that this Statement of Insurability shall form part of any policy issued in reliance upon it.

I acknowledge receipt of any required preliminary disclosures and understand that coverage will not be effective until the insurer has approved the application and the first premium, if required, has been accepted in accordance with the insurer's rules.

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