PROPOSAL / APPLICATION INDIVIDUAL DISABILITY INCOME INSURANCE

Transcription

1 PROPOSAL / APPLICATION INDIVIDUAL DISABILITY INCOME INSURANCE Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey Phone: (201) or (800) / Facsimile: (201) SUBMISSION CHECKLIST All questions, including all Part II Medical History questions, are answered completely and/or acknowledged regardless of whether or not they apply. All Yes answers include details in the space provided (i.e. dates, diagnosis, names and addresses of physicians, medication prescribed, present condition, etc.). Any answers crossed-out or covered with white-out are initialed by the Proposed Insured. Part II Medical History has been signed and dated where indicated on Page 6 by the Proposed Insured. Agreement has been signed and dated where indicated on Page 9 by the Proposed Insured and Proposed Policy Owner (if applicable). Authorization to Release Information has been signed and dated where indicated on Page 10 by the Proposed Insured and Proposed Policy Owner (if applicable). Agent Statement has been signed and dated where indicated on Page 10 by the Producing Agent. Producing Agent is already appointed with Hanleigh. If not, please contact Hanleigh at the number above. Notice and Consent for Blood Testing is completed, signed and dated by the Proposed Insured where indicated. Underwriter Copy is attached. Applicant Copy has been retained by Proposed Insured. Lloyd s Privacy Policy Statement Form LSW 1135 has been delivered to the Proposed Insured. A copy of the Illustration is attached. Generic Diligent Effort Form is completed and signed by the Producing Agent. This checklist has been provided for your convenience. Compliance with these instructions will significantly reduce unnecessary underwriting delays. Incomplete applications may be denied and returned at Underwriters discretion. Thank you for your cooperation!

2 PROPOSAL / APPLICATION INDIVIDUAL DISABILITY INCOME INSURANCE Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey Phone: (201) or (800) / Facsimile: (201) PART I GENERAL 1. Proposed Insured s Name: Residence: City: State: Zip: Date of Birth: Place of Birth: Sex: Social Security Number: 2. Name of Proposed Owner: Address of Owner: Relationship to Proposed Insured: Name of Beneficiary: (if other than Owner) Address of Beneficiary: Relationship to Proposed Insured: Contract (or other documentation) Providing for Insurable Interest: 3. Proposed Insured s Occupation: Duties and Description Occupation: Name of Employer: Business Address: Type of Business: (Check One) Corporate Partnership Single Proprietorship Date Formed: Complete the remainder of this question for the last 12 months: Proposed Insured s percent of ownership in the business: Annual Earned Income: Unearned Income: Net Worth: HMI APP 0901 Page 1

3 4. (A) Is there any group or individual disability insurance applied for or currently in force on the Proposed Insured? (B) Is this Policy intended to replace any existing coverage? (C) If yes, to any of the above, list below: Company: Policy Number: Amount: Date Issued: 5. (A) Has any application for accident, sickness, life or disability insurance submitted on behalf of the Proposed Insured ever been declined, postponed or withdrawn? (B) Has an Insurer ever modified, canceled or refused to renew such coverage? (C) If Yes, to (A) or (B) complete the following: Type of Insurance: Company Name: Policy Number: Date and reason: 6. Do you engage in any hazardous sports, hobbies or avocations, e.g., auto racing, scuba diving, hang gliding, bungee jumping, piloting, parachuting, roller blading, technical climbing, etc.? If Yes, note the type of activity involved: 7. Do you anticipate traveling overseas during the term of this policy? If Yes, please provide details (i.e. location, duration, nature of travel): PART II MEDICAL HISTORY The following information is to be completed by the Proposed Insured. Please answer to the best of your knowledge and belief. 8. (A) Name, address, and telephone number of your personal physician? (If none, so state.) HMI APP 0901 Page 2

4 (B) Date and reason last consulted? (If within the past 10 years.) (C) What was the outcome of this visit? Was treatment given or medicine prescribed? 9. (A) Have you smoked cigarettes within the last 12 months? (B) Do you use tobacco in any form? If Yes, to (A) or (B), note the details of tobacco usage and duration. 10. Have you ever been treated for, or ever had, any known indication of: (Check applicable items.) (A) Disease of eyes, ears, nose or throat? Details of Yes answers (Identify Question. Include diagnoses, dates, duration and names and addresses of all attending physicians and medical facilities.) (B) Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disease? (C) Neurological disease or disorders, Alzheimer s, Parkinson s, ALS, tremors, numbness, or Multiple Sclerosis? (D) Shortness of breath, persistent hoarseness or cough, blood spitting, bronchitis, pleurisy, asthma, chronic obstructive pulmonary disease, emphysema, tuberculosis or chronic respiratory disease? (E) Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack, congestive heart failure or other disease of the heart or blood vessels? HMI APP 0901 Page 3

5 Details of Yes answers (Identify Question. Include diagnoses, dates, duration and names and addresses of all attending physicians and medical facilities.) (F) Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, colitis, Crohn s Disease, diverticulitis, hemorrhoids, recurrent indigestion or other disease of the stomach, intestines, liver or gallbladder? (G) Sugar, albumin, blood or pus in urine, venereal disease, stone or other disease of kidney, bladder, prostate or reproductive organs? (H) Diabetes, thyroid or other endocrine disease? (I) Neuritis, sciatica, rheumatism, osteoarthritis, rheumatoid arthritis, gout or disease of the muscles or bones including the spine, back or joints? (J) Deformity, lameness or amputation? (K) Disease of the skin, lymph glands; cyst, tumor or cancer? (L) Allergies, anemia or other disease of the blood? 11. Have you ever been treated for the use of, or are you currently using, habit-forming drugs? 12. Have you within the past 5 years: (A) Had any psychiatric or physical disease not listed above? (B) Had a checkup, consultation, illness, injury, surgery? HMI APP 0901 Page 4

6 Details of Yes answers (Identify Question. Include diagnoses, dates, duration and names and addresses of all attending physicians and medical facilities.) (C) Been a patient in a hospital, clinic, sanatorium, or other medical facility? (D) Had electrocardiogram, X-ray, other diagnostic test (except for an HIV test)? If yes, please advise results. (E) Been advised to have any diagnostic test, (except for an HIV test) hospitalization or surgery, which was not completed? (F) Been out of work due to illness for more than 1 week? 13. Have you ever been diagnosed or treated by a medical professional for AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS Related Complex) in the past 10 years? 14. In the past 5 years have you had or been told you have enlarged lymph nodes and/or unexplained or unintentional weight change? 15. Are you now under medical observation or taking treatment? Have you been advised to seek treatment or has treatment been recommended for any condition? 16. Have you ever had military service deferment, rejection or discharge because of a physical or mental condition? 17. Have you ever requested or received a pension, benefits, or payment because of an injury, sickness or disability? If so, please describe the type of disability, the length of disability and the Insurance Carrier. Length of Disability: Type of Disability: Insurance Carrier: HMI APP 0901 Page 5

7 18. Statement of height and weight: Height: feet inches Weight: pounds Details of Yes answers (Identify Question. Include diagnoses, dates, duration and names and addresses of all attending physicians and medical facilities.) 19. Family History: Tuberculosis, diabetes, cancer, high blood pressure, heart or kidney disease, mental illness or suicide? Father Age if Living State of Health/Cause of Death Age At Death Mother Brothers and Sisters No. Living No. Dead 20. For female applicants only, to the best of your knowledge and belief: (A) Have you ever had any disorder of menstruation, pregnancy or of the reproductive organs or breasts? (B) Are you now pregnant? I represent that the statements and answers above in Part II Medical History are true, complete and correctly recorded to the best of my knowledge and belief. In some states we are required to inform you that: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act which may be a crime, shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Proposed Insured s Signature: Date: HMI APP 0901 Page 6

8 PART III BENEFIT SECTION Benefit Schedule: Benefit Schedule is subject to Company approval. Next to each item in the Benefit Schedule below, insert an X in the appropriate box and complete the blank spaces. Total Disability for Injury & Sickness Benefit: Monthly Benefit Benefit Period Elimination Period Term of Insurance Residual Disability Benefit: (only available if Total Disability Benefit is selected) Permanent Total Disability for Injury & Sickness Benefit: Lump Sum Benefit Elimination Period Term of Insurance PART IV PREMIUM PAYMENT The Premium is subject to Company approval. Insert an x to indicate your selection of the Premium Plan. Mode of Premium: Annual Premiums are due and payable before coverage under this Policy will start and at subsequent anniversary dates. Prepaid The Premium for the entire Term of the Policy is due and payable before coverage under the Policy will start. HMI APP 0901 Page 7

9 NOTICE TO PROPOSED INSURED/OWNER PART ONE Information regarding the Proposed Insured s insurability will be treated as confidential. Hanleigh Management, Inc., Hanleigh General Agency, Inc. ( We ) may, however, make a brief report thereof to the Medical Information Bureau Inc., a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or submit a claim for benefits to such a company, the Bureau, upon request, will supply such company with information in its file. We may also release information in its file to other insurance companies to whom the Proposed Insured and Proposed Owner may apply for life or health insurance or to whom a claim for benefits may be submitted. PART TWO In the course properly underwriting and administering this insurance coverage, We will rely heavily on information provided by the Proposed Insured and the Proposed Owner (if other than the Proposed Insured). We may also seek information from others, such as medical professionals, who have treated the Proposed Insured. In some cases, We may ask a consumer-reporting agency to collect information and submit an investigative consumer report to us. The Proposed Insured has the right to request to be interviewed in connection with the preparation of that report. The Proposed Insured may receive a copy of the report upon request. Information regarding the Proposed Insured s insurability will be treated as confidential. In some situations, and in compliance with applicable law, We may disclose necessary items of information to third parties without the Proposed Insured s specific authorization. The Proposed Insured has the right to be told about, and to see and copy if he/she wishes, items of personal information which appear in our files, including information contained in investigative consumer reports. The Proposed Insured also has the right to seek correction of information that he believes to be inaccurate. AGREEMENT IT IS UNDERSTOOD AND AGREED THAT: 1. We shall incur no liability under this Application unless a Policy is issued on this Application and the full First Premium is actually paid based on the continued insurability of the Proposed Insured as stated in this Application. 2. To the best of my knowledge, information and belief, all statements and answers in this Application are full, complete, and true and correctly recorded and bind all parties of interest to the Policy herein applied for. 3. The Proposed Insured and the Proposed Owner (if other than the Proposed Insured) also agree to provide financial statements, which shall also become a part of this Application. 4. The Proposed Insured and the Proposed Owner (if other than the Proposed Insured) also agree to provide proof of an insurable obligation or interest (as evidenced by a valid contract or agreement), which shall also become a part of this Application. 5. The acceptance of the Policy by the Proposed Insured and the Proposed Owner (if other than the Proposed Insured) will ratify any Underwriters Additions or Corrections including amendments of amount, risk, classification, age at issue, plan of insurance or benefits. However, in those states where written consent is required, any such amendment will be made only with the written consent of the Proposed Insured and the Proposed Owner (if other than the Proposed Insured). HMI APP 0901 Page 8

10 AGREEMENT (cont d) 6. No agent or medical examiner or other person, except Underwriters at Lloyd s, London, or an officer of Hanleigh Management, Inc. or Hanleigh General Agency, Inc. is authorized to make or discharge contracts or waive or change any of the conditions or provisions of any Application, Policy or receipt or to accept risk or pass upon insurability. Notice to or knowledge of any agent is not notice to or knowledge of Underwriters at Lloyd s, London, or Hanleigh Management, Inc. or Hanleigh General Agency, Inc. unless stated in this Application. The Proposed Owner, if any, otherwise the Proposed Insured, shall be the Owner of any Policy issued hereon. Signature of Proposed Insured: Signature of Proposed Owner (if other than Proposed Insured): Date: Date: Relationship: HMI APP 0901 Page 9

11 AUTHORIZATION TO RELEASE INFORMATION I hereby authorize any physician, medical practitioner, hospital, clinic, veterans administration facility, medical information service including Medical Information Bureau, Inc., urgent care facility, other medically related facility or entity, insurance or reinsurance, or Consumer Reporting Agency having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition including drug or alcohol abuse, and/or treatment of me or my dependents and other non-medical information of me, to release to Underwriters at Lloyd s, London, and/or Hanleigh Management, Inc., Hanleigh General Agency, Inc. or its designee any and all such information. This authorization includes release of information concerning psychiatric/psychological conditions and preparation of an investigative consumer report. I understand that the information obtained by use of the authorization will be used by Underwriters at Lloyd s, London, and/or Hanleigh Management, Inc. or Hanleigh General Agency, Inc. to determine eligibility for insurance or to determine eligibility for benefits under the Policy. Any information obtained will not be released by the Insurer except to reinsuring companies, insurance support organizations or other person or organizations performing business or legal services in connection with my application, or as may be otherwise lawfully required. I know that I may request to receive a copy of this authorization. I know that I may request to be interviewed if any investigative consumer report is prepared in connection with this application. I agree that a photographic copy of this authorization shall be as valid as the original. This authorization shall be valid for twenty-six (26) months from the date signed. Signature of Proposed Insured: Signature of Proposed Owner (if other than Proposed Insured) Date: Date: Relationship: AGENT STATEMENT I certify that I have truly and accurately recorded all the information given to me by the applicant, and I certify that I know of no other medical information about the person applying for coverage other than that contained on this application. I certify that the applicant has either filled out the application or has personally reviewed the completed application. I have explained all policy benefits, exclusions and limitations. Producing Agent s Signature: Date: Producing Agent s Name (please print): Agency Name: HMI APP 0901 Page 10

12 Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey Phone: (201) or (800) / Facsimile: (201) NOTICE AND CONSENT FOR BLOOD TESTING WHICH MAY INCLUDE AIDS VIRUS (HIV) ANTIBODY/ANTIGEN TESTING To determine your insurability, the insurer named above (the Insurer) has requested that you provide a sample of your blood for testing and analysis. All tests will be performed by a licensed laboratory. Unless precluded by law, tests may be performed to determine the presence of antibodies or antigens to the Human Immunodeficiency Virus (HIV), also known as the AIDS virus. The HIV antibody test that we perform is actually a series of tests done by a medically accepted procedure. The HIV antigen test directly identifies AIDS viral particles. These tests are extremely reliable. Other tests which may be performed include determinations of blood cholesterol and related lipids (fats) and screening for liver or kidney disorders, diabetes, and immune disorders. All tests will be treated confidentially. They will be reported by the laboratory to the Insurer. When necessary for business reasons in connection with insurance you have or have applied for with the Insurer, the Insurer may disclose test results to others such as affiliates, reinsurers, employees, or contractors. If the Insurer is a member of the Medical Information Bureau (MIB, Inc.), and if the test results for HIV antibodies/antigens are other than normal, the Insurer will report to the MIB, Inc. a generic code which signifies only a non specific blood abnormality. If your HIV test is normal, no report will be made about it to the MIB, Inc. Other test results may be reported to the MIB, Inc. in a more specific manner. The organizations described in this paragraph may maintain the test results in a file or data bank. There will be no other disclosure of test results or even that the tests have been done except as may be required or permitted by law or as authorized by you. If your HIV test results are normal, no routine notification will be sent to you. If the HIV test results are other than normal, the Insurer will contact you. The Insurer may also contact you if there are other abnormal test results which, in the Insurer s opinion, are significant. The Insurer may ask you for the name of a physician or other health care provider to whom you may authorize disclosure and with whom you may wish to discuss the results. Positive HIV antibody/antigen test results do not mean that you have AIDS, but that you are at significantly increased risk of developing AIDS or AIDS related conditions. Federal authorities say that persons who are HIV antibody/antigen positive should be considered infected with the AIDS virus and capable of infecting others. Positive HIV antibody or antigen test results or other significant blood abnormalities will adversely affect your application for insurance. This means that your application may be declined, that an increased premium may be charged, or that other policy changes may be necessary. I have read and I understand this Notice and Consent For Blood Testing which may include AIDS Virus (HIV) Antibody/Antigen Testing. I voluntarily consent to the withdrawal of blood from me by needle, the testing of that blood, and the disclosure of the test results as described above. I understand that I have the right to request and receive a copy of this authorization. A photocopy of this form will be as valid as the original. Proposed Insured Date of Birth Signature of Proposed Insured or Parent/Guardian Date State of Residence HMI HIV 0901 UNDERWRITER COPY APPLICANT COPY

13 Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey Phone: (201) or (800) / Facsimile: (201) NOTICE AND CONSENT FOR BLOOD TESTING WHICH MAY INCLUDE AIDS VIRUS (HIV) ANTIBODY/ANTIGEN TESTING To determine your insurability, the insurer named above (the Insurer) has requested that you provide a sample of your blood for testing and analysis. All tests will be performed by a licensed laboratory. Unless precluded by law, tests may be performed to determine the presence of antibodies or antigens to the Human Immunodeficiency Virus (HIV), also known as the AIDS virus. The HIV antibody test that we perform is actually a series of tests done by a medically accepted procedure. The HIV antigen test directly identifies AIDS viral particles. These tests are extremely reliable. Other tests which may be performed include determinations of blood cholesterol and related lipids (fats) and screening for liver or kidney disorders, diabetes, and immune disorders. All tests will be treated confidentially. They will be reported by the laboratory to the Insurer. When necessary for business reasons in connection with insurance you have or have applied for with the Insurer, the Insurer may disclose test results to others such as affiliates, reinsurers, employees, or contractors. If the Insurer is a member of the Medical Information Bureau (MIB, Inc.), and if the test results for HIV antibodies/antigens are other than normal, the Insurer will report to the MIB, Inc. a generic code which signifies only a non specific blood abnormality. If your HIV test is normal, no report will be made about it to the MIB, Inc. Other test results may be reported to the MIB, Inc. in a more specific manner. The organizations described in this paragraph may maintain the test results in a file or data bank. There will be no other disclosure of test results or even that the tests have been done except as may be required or permitted by law or as authorized by you. If your HIV test results are normal, no routine notification will be sent to you. If the HIV test results are other than normal, the Insurer will contact you. The Insurer may also contact you if there are other abnormal test results which, in the Insurer s opinion, are significant. The Insurer may ask you for the name of a physician or other health care provider to whom you may authorize disclosure and with whom you may wish to discuss the results. Positive HIV antibody/antigen test results do not mean that you have AIDS, but that you are at significantly increased risk of developing AIDS or AIDS related conditions. Federal authorities say that persons who are HIV antibody/antigen positive should be considered infected with the AIDS virus and capable of infecting others. Positive HIV antibody or antigen test results or other significant blood abnormalities will adversely affect your application for insurance. This means that your application may be declined, that an increased premium may be charged, or that other policy changes may be necessary. I have read and I understand this Notice and Consent For Blood Testing which may include AIDS Virus (HIV) Antibody/Antigen Testing. I voluntarily consent to the withdrawal of blood from me by needle, the testing of that blood, and the disclosure of the test results as described above. I understand that I have the right to request and receive a copy of this authorization. A photocopy of this form will be as valid as the original. Proposed Insured Date of Birth Signature of Proposed Insured or Parent/Guardian Date State of Residence HMI HIV 0901 UNDERWRITER COPY APPLICANT COPY

14 PRIVACY POLICY STATEMENT Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey Phone: (201) or (800) / Facsimile: (201) UNDERWRITERS AT LLOYD S LONDON We, the Certain Underwriters at Lloyd s, London that have underwritten this insurance want you to understand how we protect the confidentiality of nonpublic personal information we collect about you. INFORMATION WE COLLECT We collect nonpublic personal information about you from the following sources: a) Information we receive from you on applications or other forms; b) Information about your transactions with our affiliates, others or us; and c) Information we receive from a consumer-reporting agency. INFORMATION WE DISCLOSE We do not disclose any nonpublic personal information about you to anyone except as is necessary in order to provide our products or services to you or otherwise as we are required or permitted by law (e.g., a subpoena, fraud investigation, regulatory reporting etc.) CONFIDENTIALITY AND SECURITY We restrict access to nonpublic personal information about you to our employees, our affiliates employees or others who need to know that information to service your account. We maintain physical, electronic, and procedural safeguards to protect your nonpublic personal information. CONTACTING US If you have any questions about this privacy statement or would like to learn more about how we protect your privacy, please contact the agent/broker who handled this insurance.

15 50 Tice Blvd., Suite 122, Woodcliff Lake, NJ LOCAL: FAX: DILIGENT EFFORT FORM Producing Agent SSN Name of Agency Has sought to obtain: Type of Coverage Named Insured for from the following authorized Insurers currently writing this type of coverage: (1) Authorized Insurer Person Contacted Telephone Number NAIC# Date of Contact The reason(s) for declination by the insurer was (were) as follows: (2) Authorized Insurer Person Contacted Telephone Number NAIC# Date of Contact The reason(s) for declination by the insurer was (were) as follows: (3) Authorized Insurer Person Contacted Telephone Number NAIC# Date of Contact The reason(s) for declination by the insurer was (were) as follows: Signature of Producing Agent Printed or Typed Name of Producing Agent

16 NOTICE: 1. THE INSURANCE POLICY THAT YOU ARE APPLYING TO PURCHASE IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED NONADMITTED OR SURPLUS LINE INSURERS. 2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS. 3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED. 4. THE INSURER SHOULD BE LICENSED EITHER AS A FOREIGN INSURER IN ANOTHER STATE IN THE UNITED STATES OR AS A NON-UNITED STATES (ALIEN) INSURER. YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR SURPLUS LINE BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE AT THE FOLLOWING TOLL-FREE TELEPHONE NUMBER: ASK WHETHER OR NOT THE INSURER IS LICENSED AS A FOREIGN OR NON-UNITED STATES (ALIEN) INSURER AND FOR ADDITIONAL INFORMATION ABOUT THE INSURER. YOU MAY ALSO CONTACT THE NAIC S INTERNET WEB SITE AT 5. FOREIGN INSURERS SHOULD BE LICENSED BY A STATE IN THE UNITED STATES AND YOU MAY CONTACT THAT STATE S DEPARTMENT OF INSURANCE TO OBTAIN MORE INFORMATION ABOUT THAT INSURER. 6. FOR NON-UNITED STATES (ALIEN) INSURERS, THE INSURER SHOULD BE LICENSED BY A COUNTRY OUTSIDE OF THE UNITED STATES AND SHOULD BE ON THE NAIC S INTERNATIONAL INSURERS DEPARTMENT (IID) LISTING OF

17 APPROVED NONADMITTED NON-UNITED STATES INSURERS. ASK YOUR AGENT, BROKER, OR SURPLUS LINE BROKER TO OBTAIN MORE INFORMATION ABOUT THAT INSURER. 7. CALIFORNIA MAINTAINS A LIST OF APPROVED SURPLUS LINE INSURERS. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: 8. IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY BROKER S FEE CHARGED FOR THIS INSURANCE WILL BE RETURNED TO YOU. Date: Insured: D-1 (Effective July 21, 2011)