Insurance Youth Life Application

INSURANCE YOUTH LIFE APPLICATION

Insured (Youth) Information

Insured Name:    Date of Birth:    Sex:

Place of Birth:    Social Security No.:    Current Grade/Age:

Parent/Guardian (Applicant) Information

Policy Details

Policy Type: Term Whole Life Universal Life Juvenile Whole Life

Coverage Options / Riders

Select desired riders (if available under chosen product):
Accidental Death Benefit Rider Waiver of Premium for Disability Additional Child Term Rider Critical Illness Rider

Beneficiary Designation

Primary Beneficiary 1:    Relationship:    Share %:

Contingent Beneficiary 1:    Relationship:    Share %:

Medical & Health Information

Does the insured currently use tobacco or nicotine products?   Yes   No

Has the insured ever been diagnosed with or treated for a serious illness, congenital condition, developmental disorder, or been hospitalized?   Yes   No

Is the insured currently taking any prescription medication?   Yes   No

Has the insured participated in hazardous activities (e.g., aviation, diving, motorsports) or plan to engage in such activities in the next 12 months?   Yes   No

Exclusions and Important Notices

The policy will include standard exclusions applicable to youth life insurance. Typical exclusions include death resulting from suicide within the contestable period, intent to inflict self-harm, participation in illegal acts, active duty in declared war, and losses arising from fraudulent acts of the insured or beneficiary. Riders may have additional exclusions or conditions. The company may require proof of insurability and will determine acceptance based on underwriting criteria.

Declarations, Authorization & Certification

By signing below, I certify that the statements in this application are 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 the policy, or denial of a claim. I authorize any licensed physician, medical practitioner, hospital, clinic, other medical or medically related facility, insurance company, consumer reporting agency, or other organization, institution or person that has records or knowledge of me or the insured to release to the insurer or its representatives any such information for the purpose of evaluating this application for insurance. This authorization remains valid for twenty-four months from the date signed unless revoked in writing. A photostatic copy of this authorization shall be as valid as the original.

I acknowledge that coverage will not become effective until the company has approved the application and the first premium has been paid, except as may be provided under a conditional receipt (if issued). I understand that if a conditional receipt is issued, coverage is subject to its terms and conditions and is conditional on the answers provided herein. I acknowledge receipt of the Fraud Notice below and understand the consequences of providing false information.

Any person who knowingly presents false information in an application for insurance may be guilty of insurance fraud and subject to civil or criminal penalties under applicable law. This notice is provided to the applicant in accordance with state law and may be supplemented by additional statements specific to the state of residence.

Agent / Producer Information (if applicable)

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