Liberty National Life Insurance Policy Lookup

PART 1

Application is hereby made to exchange or convert the above numbered policy. (The policy is attached for such change.)

The new policy is to contain the following coverage:

2. The reason for the requested change:

NOTE: COMPLETE IF EXCHANGING OR CONVERTING SPOUSE/DEPENDENT COVERAGE

3. Is the insurance applied for intended to replace or change any now in force? Yes No

If yes, comply with the applicable replacement regulation or rule.

COMPLETE PART 2 WHEN:

a) Adding coverage on primary insured;

b) Adding spouse coverage; or

c) Adding family coverage.

CORRECTIONS AND AMENDMENTS (Home Office Use Only)

Effective Date for Policy Change

CONDITIONS AND LIMITATIONS

1. The old policy will terminate on the effective date for policy change. Under no circumstances will any benefit be payable under both policies.

2. The new policy shall contain the ratings, restrictions, limitations or exclusions applicable to the old policy.

3. Any reference to the effective date in the provision of the new policy, “Time Limit on Certain Defenses,” will mean the Effective Date of this requested policy change with respect to any family member added to coverage or to any increase in existing coverage. With respect to persons covered under the old policy on its Effective Date or Date of Issue, the “Time Limit on Certain Defenses” will run from the original Effective Date of the old policy.

4. The acceptance of any policy issued hereon shall constitute ratification of any and all changes in or additions to this application indicated by the Company in the space above entitled “Corrections and Amendments,” except that no change in amount, classification, age at issue, plan of insurance or benefits shall be effective unless agreed to in writing.

5. The policy changes herein requested shall not be effective until the Request for Policy Change is approved, the policy manually delivered to the named insured and the necessary payment has been received by the Company.

Only the information which the applicant has given in the answers to the questions on the application or in the company records will be used to evaluate the eligibility for this insurance. This information will not be disclosed to any other company or person without written authorization.

PART 2 FOR CANCER, HOSPITALIZATION OR ACCIDENT COVERAGE

Complete if so instructed in part 1

Liberty National Life Insurance Company

Conversion of expiring juvenile coverage. Date:

Divorce from primary insured. Date:

Other Date:

COMPLETE THIS SECTION FOR HOSPITALIZATION COVERAGE ONLY

COMPLETE THIS SECTION FOR CANCER POLICY ONLY

COMPLETE THIS SECTION FOR ACCIDENT COVERAGE ONLY

1. Name of each insured or proposed insured

I, the Insured, hereby declare that the answers below are complete and true to the best of my knowledge and belief, and expressly agree that they shall be the bases for the policy change(s) applied for under policy number . (ALL QUESTIONS MUST BE ANSWERED.)

AGENT’S IDENTIFICATION

USE IMPRINTER HERE

AGENT REMARKS