Limited Pay Policy (L-222B) - Underwriting Guidelines
|
|
- Roxanne Stanley
- 8 years ago
- Views:
Transcription
1 Limited Pay Policy (L-222B) - Underwriting Guidelines 1 Addiction/Abuser Drug - Past or Present Presently Recovered - AA for last 2 years 2 Aids 3 Alcoholic Presently Recovered - AA for last 2 years 4 Alzheimer's 5 Anemia Sickle Cell Anemia 6 Aneurysm 7 Arrhythmias 8 Arteriosclerosis Under Age 50 Over Age 50 but under 70 Over Age 70 Any Age Combined w/ Diabetes 9 Artery Bypass Within 4 years Over 4 years 10 Arthritis 11 Asthma 12 Bronchiectasis 13 Bronchitis 1
2 14 Cancer Currently exists in Body Brain Lungs Liver Skin - Recovered 1 or more yrs. Has moved from original site 15 From Recovery or Last treatment 0 through 3 years 4 years and over 16 Cerebral Palsy 17 Chronic Obstructive Pulmonary With oxygen 18 Cirrhosis 19 Congestive Heart Failure diagnosed within last 4 years diagnosed over 4 years ago 20 Confinement Wheelchair Bed 21 Coronary Artery Disease 22 Coronary Thrombosis diagnosed within last 2 years diagnosed within last 2 years 23 Crohn's Disease Recovery less than 5 years Recovery more than 5 years 24 Cystic Fibrosis Lung Disorder 25 Diabetes Onset Age
3 Onset Age 40 and Diet controlled Onset Age 40 & 60 units or less Over 60 units per day - any age Duration over 15 years 26 Diabetes Combined with the following: High Blood Pressure Heart disease Hardening of the Arteries Extreme Overweight Other Impairments 27 Dialysis Kidney - Currently receiving Kidney - Previously received 28 Disabled Physically Mentally 29 Diverticulitis 30 Down Syndrome 31 Drug Addiction Drug - Past or Present 32 Drug Rehab Currently residing 33 Emphysema 34 Hardening of Arteries With oxygen Under Age 50 Over Age 50 but under 70 Over Age 70 Any Age Combined w/ Diabetes 35 Heart Attack diagnosed within last 2 years 3
4 36 Heart Disease diagnosed within last 2 years 37 Heart Enlargement diagnosed within last 4 years diagnosed over 4 years ago 38 Hepatitis 39 Hernia 40 High Blood Pressure Controlled with medication Combined with Diabetes Combined with heart Disease Combined with Kidney Disease 42 Hospital Patient Currently residing in Hospital 43 Impaired Severely or markedly 44 Incontinent Loss of bladder and bowel 45 Kidney Disease Chronic On Dialysis Renal Failure nephritis Kidney Stones nephrectomy Pancreas 46 Leukemia Currently exists in Body From Recovery or Last treatment 0 through 3 years 4 years and over 47 Life Support Currently being sustained 4
5 Previously sustained 48 Lung Disorder Cancer Chronic Obstructive Pulmonary COPD + Oxygen Cystic fibrosis Silicosis 49 Lupus Joint disease with Kidney failure 50 Nervous/Mental Disorders Alzheimer's Down's Syndrome Paranoid Parkinson's Disease Psychotics Psychoneurosis Retardation Schizophrenia 51 Mental Institution Currently residing in Institution 52 Myocardial Infarction diagnosed within last 2 years 53 Nursing Home Currently residing in Institution 54 Osteoporosis 55 Pacemaker Within 4 years Over 4 years 56 Paranoid 57 Parkinson's Disease 58 Psychotics 5
6 59 Psychoneurosis 60 Resident of the following 61 Respiratory Disorders Drug/Alcohol Rehabilitation Hospital mental Institution nursing Home Veterans Hospital Asthma Bronchiectasis Bronchitis 62 Retardation Mental Disorder 63 Silicosis Lung Disorder 64 Suicide within last 5 years 6 years or more 65 Schizophrenia Mental Disorder 66 Stroke within 1 year Over 1 year 67 Terminally Ill Any disease 68 Tuberculosis 69 Tumor Benign Malignant Currently exists in Body From Recovery or Last treatment 0 through 3 years 4 years and over 6
7 70 Ulcers 71 Ulcerative Colitis 7
Can You Purchase Life Insurance If You
Can You Purchase Life Insurance If You Are Diabetic Have Heart Disease Are Fighting MS Abused Drugs or Alcohol Have a History of Cancer Or Other Serious Illness InsuranceNebraska.org (800) 882-5009 The
More informationGolden Solution. Whole Life Insurance. American-Amicable Life Insurance Company of Texas
Golden Solution Whole Life Insurance American-Amicable Life Insurance Company of Texas AA9504(10/06) CN6-019 Golden Solution Whole Life Insurance Policy An economical way to free your loved ones from financial
More informationCritical PROVIDER FIELD UNDERWRITING GUIDE & RATE BOOK
G T L Critical PROVIDER FIELD UNDERWRITING GUIDE & RATE BOOK 10 OR 20 YEAR RENEWABLE TERM LIFE INSURANCE WITH A CRITICAL ILLNESS ACCELERATED BENEFIT RIDER WHICH PROVIDES CASH BENEFITS FOR 18 CRITICAL CONDITIONS
More informationBlueCross BlueShield of Arizona, Inc. Group 635 Voluntary Long-Term Care Insurance Certificate # GRP11-342-MA-AZ-200
Mailing Address: Enrollment Form CARE DIRECTIONS PREMIER BlueCross BlueShield of Arizona, Inc. Group 635 Voluntary Long-Term Care Insurance Certificate # GRP11-342-MA-AZ-200 DO NOT USE - MICROFILM USE
More informationPhoenix Remembrance Life
Phoenix Remembrance Life W e You Asked New Printer- Friendly Design! D e l i v e r e d Field Underwriting Guide For agent use only. Not for distribution to the public as sales literature. Phoenix Remembrance
More informationHealth First Insurance, Inc. Medicare Supplement Application 2013
6450 US Highway 1, Rockledge, FL 32955 Customer Service: 321.434.4822 Toll-free 1.855.443.4735 TTY relay 1.800.955.8771 Monday through Friday from 8 am to 8 pm, Saturday from 8 am to noon A. General Information
More informationApplication for Life Insurance American Memorial Life Insurance Company P.O. Box 2730 Rapid City, SD 57709
Application for Life Insurance American Memorial Life Insurance Company P.O. Box 2730 Rapid City, SD 57709 HOME OFFICE USE ONLY # Any person who knowingly presents a false or fraudulent claim for payment
More informationFacing the challenges of CRITICAL ILLNESS
Facing the challenges of CRITICAL ILLNESS INTRODUCTION What is insurance? In life, we are all faced with threats which, if they occurred, would result in financial loss Insurance is the process of protecting
More informationGUIDE. Prepare for Your Phone Interview and Medical Exam.
GUIDE Prepare for Your Phone Interview and Medical Exam. WHAT YOU NEED TO HAVE, KNOW, AND DO. All information gathered during the interview and exam will be shared only with those who need it in order
More informationAll shaded fields on the attached Assurance Final Expense application are required fields.
- IMPORTANT- All shaded fields on the attached Assurance Final Expense application are required fields. Any required fields with insufficient data, along with any missing, incomplete or outstanding requirements
More informationAgent Reference Guide
Agent Reference Guide For Guaranteed Cost or Price Estimate Only Funeral Planning SM Forethought Encore Advance Whole life insurance issued by Forethought Life Insurance Company FOR AGENT USE ONLY NOT
More informationApplication for Medicare Supplement
Application for Medicare Supplement This application is subject to the approval of Blue Cross and Blue Shield of Nebraska. P.O. Box 2417 Omaha, NE 68103-2417 1 Tell us about yourself. Name (First, Middle,
More informationLong Term Care Insurance - Application for Coverage
Long Term Care Insurance - Application for Coverage How to apply for coverage. 1. Each person (member, spouse, parent, and/or adult child) applying for Long Term Care coverage must complete and submit
More informationCOLUMBIAN LIFE INSURANCE COMPANY
APPLICATION FOR WHOLE LIFE INSURANCE POLICY COLUMBIAN LIFE INSURANCE COMPANY HOME OFFICE: CHICAGO, IL ADMINISTRATIVE SERVICE OFFICE: PO Box 4850, Norcross, GA 30091-4850 MAIL POLICY TO: Agent Owner 1.
More informationCSA FRATERNAL LIFE A Fraternal Benefit Society P.O. Box 249, Lombard, Illinois 60148. Application for Life Insurance
FOUNDED MARCH 4, 1854 Personal Information 1. Full name of Proposed Insured: Lodge Name: CSA FRATERNAL LIFE A Fraternal Benefit Society P.O. Box 249, Lombard, Illinois 60148 Application for Life Insurance
More informationWL TERM * Addition of Coverage IUL IUL Increase Reinstatement *Child/Grandchild Policy not available with TERM
Provident Life and Accident Insurance Company 1 Fountain Square Chattanooga, Tennessee 37402 APPLICATION FOR INDIVIDUAL VOLUNTARY LIFE INSURANCE / LONG TERM CARE INSURANCE Child and/or Grandchild* Product
More informationSETTLERS LIFE INSURANCE COMPANY Madison, Wisconsin
Company Use Only SETTLERS LIFE INSURANCE COMPANY Madison, Wisconsin Administrative Office: P.O. Box 8600 Bristol, Virginia 24203 Life Insurance Application A. Proposed Insured Information First Name MI
More informationPhoenix Simplicity Index Life SM
Phoenix Simplicity Index Life SM Field Underwriting Guide Phoenix Simplicity Index Life is indexed universal life insurance underwritten on a simplified issue basis. There are no medical examinations,
More informationApplication for Critical Care Insurance to: Guarantee Trust Life Insurance Company 1275 Milwaukee Avenue, Glenview, IL 60025 (800) 338-7452
Application for Critical Care Insurance to: Guarantee Trust Life Insurance Company 1275 Milwaukee Avenue, Glenview, IL 60025 (800) 338-7452 AGENT NOTE: Please pre-qualify the Applicant (s) with Section
More informationSocial Security No. - - Male Female E-mail Issue Age. City State ZIP - Personal Phone No. ( ) - Birth State/Country Height ft. in. Weight lbs.
PLEASE PRINT WITH BLACK INK ASSURITY LIFE INSURANCE COMPANY 1526 K Street, PO Box 82533, Lincoln NE 68501-0926 Primary Proposed Insured - Employee APPLICATION FOR INSURANCE New application Takeover Addition,
More informationMade to Move Physical Therapy, Inc. 615 N Nash St., Ste # 306 El Segundo, CA 90245 310.535.0008
Name Last First MI Date Current/Permanent address City State Zip Phone H W Cell Email Address: Marital Status Single Married Other Date of Birth: Age: Gender Male Female Spouses DOB: Employer Occupation
More informationPlease advise if you have received the following documents with this application:
GROUP LONG TERM CARE INSURANCE APPLICATION Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 The policy for long term care insurance is intended to be a federally qualified
More informationQualifying Events. 100% Benefit. 25% Benefit
Qualifying Events Condition Advanced Alzheimer s Disease, illness induced coma, heart attack, life-threatening cancer, major organ transplant, stroke, amyotrophic lateral sclerosis (Lou Gehrig s disease),
More informationMailing Address: PO Box 696700 San Antonio, TX 78269-6700
Application for Individual Life Insurance Policy Issued by One Moody Plaza, Galveston, TX 77550-7947 Phone Number: 877-862-0759 *APP* page 1 of 6 Mailing Address: PO Box 696700 San Antonio, TX 78269-6700
More informationAsteron Life Personal Insurance
Asteron Life Personal Insurance What lump sum covers are available with Asteron Life Personal Insurance? Life Cover Life Cover insurance pays a lump sum of money if you pass away or become terminally ill.
More informationAetna Individual Medicare Supplement Plan Application Aetna Life Insurance Company PO Box 13547, Pensacola, FL 32591-3547
Aetna Individual Medicare Supplement Plan Application Aetna Life Insurance Company PO Box 13547, Pensacola, FL 32591-3547 INSTRUCTIONS: To be considered complete, all sections on this form must be filled
More informationSIMPL (Simplified Issue Market PermaLife) & MODIFIED WHOLE LIFE (MWL) FIELD UNDERWRITING GUIDE
SIMPL (Simplified Issue Market PermaLife) & MODIFIED WHOLE LIFE (MWL) FIELD UNDERWRITING GUIDE CONDITION SIMPL MWL AIDS/HIV Positive: Diagnosed at any time -----------------------------------------------------------------------------------------------------------------------
More informationAdvantageGuard. Underwriting Guide
Standard Life and Accident Insurance Company AdvantageGuard Whole Life Insurance Underwriting Guide UGFE612 AdvantageGuard Whole Life Insurance Product Specifications Issue Ages: 18-85 Underwriting Male
More informationBirth Date: Sex: Home Phone Number:
A 35674 To apply for AmeriHealth Medigap Plans... Please reference the enclosed AmeriHealth Medigap Plans Outline of Coverage for the monthly premium based on your plan. Check the ONE plan for which you
More informationAsteron Life Business Insurance
Asteron Life Business Insurance What lump sum covers are available with Asteron Life Business Insurance? Life Cover Life Cover pays a lump sum of money if you pass away or become terminally ill. Total
More informationAgent Reference Guide
Agent Reference Guide Preneed Insurance Coverage Product Features PRENEED LIFE INSURANCE Issue Ages 1 0-99 0-105 Initial Face Amount/Premiums 2 $500 - $25,000 $500 - $25,000 PRENEED IMMINENT ANNUITY Payment
More informationLONG TERM CARE INSURANCE. A Registered Investment Advisor Provides an Answer Outline
LONG TERM CARE INSURANCE A Registered Investment Advisor Provides an Answer Outline There is no single plan that suits all needs. Choices become a matter of cost, available funds, shared care requirement,
More informationSUPER CARE CRITICAL ILLNESS PROTECTOR
SUPER CARE CRITICAL ILLNESS PROTECTOR At ACE Life, we are committed to helping our valued customers achieve financial security and have a peace of mind through our comprehensive range of life insurance
More informationUnderwriting Criteria and Requirements
Underwriting Criteria Underwriting Criteria Preferred Plus Preferred Standard Plus Standard Impairments No personal history of disease or impairment that would affect mortality No personal history of disease
More informationHome Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone #
Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Application Type: New Enrollee Change to Existing
More informationThe Baltimore Life Insurance Company
The Baltimore Life Insurance Company 10075 Red Run Boulevard Owings Mills, MD 21117-4871 800.628.5433 www.baltlife.com Application for Life Insurance and Single Premium Annuity 1. Proposed Insured/Annuitant
More informationCritical Illness Direct
Critical Illness Direct Specified Disease/Condition & Major Organ Transplant Plan Proprietary and Confiden/al. All products underwri7en by The Chesapeake Life Insurance Company SM Critical Illness Direct
More informationSOUTH PALM CARDIOVASCULAR ASSOCIATES, INC. CHARLES L. HARRING, M.D. NEW PATIENT INFORMATION FORM. Patient Name: Home Address:
NEW PATIENT INFORMATION FORM Today s Date: Referred by: Patient Name: (First) (Last) Date of Birth: Gender: M / F SSN: Home Address: Home Phone (Area Code & No.): ( ) - Cell Phone: ( ) - Secondary Address
More informationHow To Pay For Critical Illness Insurance From The Ihc Group
You ve protected your family s financial future by purchasing life and health insurance. Critical Illness Insurance It s cash when you need it. You choose how to spend it. So you can focus on getting well.
More informationYou can relax, knowing your final wishes will be respected.
Memorial Fund You can relax, knowing your final wishes will be respected. Humana Financial Protection Products GNA06XOHH 11/09 MI Memorial Fund Ensure financial peace of mind for you and your family. You
More informationPatient Information Form Pain Management Center at Phoebe
Patient Information Form Pain Management Center at Phoebe Please complete the following form, so that we may facilitate your visit Occupation: or (circle) Retired, Disabled Homemaker, Full time student
More informationHome Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone #
Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Application Type: New Enrollee Change to Existing
More informationGeorgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD
Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD Responsible Party Telephone Number Date Name of Child Date of Birth Time of Birth Sex Resident County Placement County
More informationMedical Matters Action Checklists
Medical Matters Action Checklists The following Action Checklists are included in Chapter 5: Medical History Personal Medication Record Health Care Power of Attorney Medical Orders (Do Not Resuscitate/POLST)
More informationAt Risk: Pre-Existing Conditions Could Affect 1 in 2 Americans:
At Risk: Pre-Existing Conditions Could Affect 1 in 2 Americans: 129 Million People Could Be Denied Affordable Coverage Without Health Reform Introduction According to a new analysis by the Department of
More informationAPPLICATION FOR MEDICARE SUPPLEMENT COVERAGE
CENTRAL STATES INDEMNITY CO. OF OMAHA Home Office: Omaha, NE Administration: P.O. Box 10816 Clearwater, Florida 33757-8816 APPLICATION FOR MEDICARE SUPPLEMENT COVERAGE SECTION A. PROPOSED INSURED INFORMATION
More informationClosed Sub-TOI: L08.000 Life - Other Co Tr Num: 8003-0411 State Status: Approved-Closed
SERFF Tracking Number: BALT-127119919 State: Arkansas Filing Company: The Baltimore Life Insurance Company State Tracking Number: 48569 Company Tracking Number: 8003-0411 TOI: L08 Life - Other Sub-TOI:
More informationClosed Sub-TOI: L08.000 Life - Other Co Tr Num: BANRD-01 State Status: Approved-Closed
Project Name/Number: / 01 Filing at a Glance Company: Banner Life Insurance Company SERFF Tr Num: FNBL-126416557 State: Arkansas TOI: L08 Life - Other SERFF Status: Closed-Approved- State Tr Num: 44441
More informationApplication for Blue Shield of California Medicare Supplement plans
Application for Blue Shield of California Medicare Supplement plans FOR OFFICE USE ONLY Here's how to apply Accept. code Plan type Market code 1 Provide ALL requested information and print clearly in blue
More informationEnjoy a position of vantage, come what may.
Enjoy a position of vantage, come what may. prucrisis covervantage While you have achieved much in life and you and your family enjoy the benefits of success, there may be times when the unexpected happens.
More informationLA OWCA Second Injury Board Knowledge Questionnaire WARNING
1001 North 23 rd Street Post Office Box 44187 Baton Rouge, LA 70804-4187 (O) 225-342-7866 800-201-2493 (F) 225-219-5968 Bobby Jindal, Governor Curt Eysink, Executive Director Office of Workers Compensation
More informationAgent Reference Guide
2016-2017 Policy Year Agent Reference Guide Beginning in June 2016, Security Health Plan will implement several changes to the way it handles the application and effectuation process. The enhancements
More informationINSTRUCTIONS CHECKLIST
These instructions have been designed for you to simplify the application process. Read these instructions in full before you begin. If you have any questions, please call Medipac for further assistance
More informationProgressive Care Insurance for life A NEW TYPE OF INSURANCE
Progressive Care Insurance for life A NEW TYPE OF INSURANCE New Progressive Care from Sovereign Progressive Care is a type of insurance that is new to New Zealand. It s not a traditional all-or-nothing
More informationIKHLASlink Comprehensive Critical Illness Benefit Secure Takaful Rider
IKHLASlink Comprehensive Critical Illness Benefit Secure Takaful Rider 1. IKHLASlink Comprehensive Critical Illness Benefit Secure Takaful Rider Securing life uncertainties. With IKHLASlink Comprehensive
More informationFor customers Friends Life Individual Protection. Childcover benefit
For customers Friends Life Individual Protection Childcover benefit Helping to protect the whole family Most parents don t want to think about what would happen if their child became critically ill. However,
More informationenvia HYBRID CRITICAL ILLNESS INSURANCE PROGRAM
envia HYBRID CRITICAL ILLNESS INSURANCE PROGRAM So that you can concentrate on what s really important - getting better. Introducing the first Critical Illness program to offer BOTH immediate reimbursement
More informationLA OWCA Second Injury Board Knowledge Questionnaire WARNING
1001 North 23 rd Street Post Office Box 44187 Baton Rouge, LA 70804-4187 (O) 225-342-7866 800-201-2493 (F) 225-219-5968 Bobby Jindal, Governor Curt Eysink, Executive Director Office of Workers Compensation
More informationComplete coverage. Unbeatable value.
Quest Travel Insurance Complete coverage. Unbeatable value. Quest with confidence, anytime, anywhere! Quest protects you when nothing else can, with: Future stability coverage: Stable now? Not sure you
More informationEVIDENCE OF INSURABILITY AND ENROLLMENT FORM BIRTHDATE (MM/DD/YEAR) RESIDENT PHONE NUMBER EMPLOYER
AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) JACKSONVILLE, FLORIDA 32224 c New Certificate c Change/Increase Certificate # Remarks EVIDENCE OF INSURABILITY AND ENROLLMENT FORM GENERAL INFORMATION SECTION
More informationAdult Health Nursing
Adult Health Nursing 1. Course Title: Adult Nursing 2. Course Number: (301) 3. Credit Hours: Total (6) credits: Theory (3) credits Clinical (3) credits 4. Course Calendar: Total (12) hours Weekly of (15)
More informationTravelCare Medical Questionnaire Instruction Sheet for Agents
TravelCare Medical Questionnaire Instruction Sheet for Agents Helpful Reminders: We want your client to be comfortable when completing the Medical Questionnaire. It is important that you remind your client
More informationCare from the Beginning. ManuCompleteCare (I)
Care from the Beginning ManuCompleteCare (I) Benefits at a Glance: 100% 100% Lump sum payout of the basic sum insured for covered critical illnesses under the Comprehensive Critical Illness Benefit or
More informationPatient & Medical Professional US Online Panel
Patient & Medical Professional US Online Panel Patient & Medical Professional US Online Panel Over 500K validated US online double opt-in panelists motivated to share their opinions in research! Since
More informationApplication for Medicare Supplement Insurance Plan
Application for Medicare Supplement Insurance Plan Instructions Complete this application in ink and sign on the appropriate line in PART THREE. To be considered for coverage, you must be age 65 or over,
More informationSun Life and Health Insurance Company (U.S.)
Sun Life and Health Insurance Company (U.S.) One Sun Life Executive Park, Wellesley Hills, MA 02481] [800-247-6875 Evidence of Insurability Cover Page Employer Instructions Complete this cover page and
More informationSenior Whole Life Transmittal
Senior Whole Life Transmittal Applicant Information: Insured Name: underwriting process. Please advise the best time and place to contact the applicant: We may need to contact the applicant for more information
More informationNew Business Applications and Supporting Documents FOR USE IN MASSACHUSETTS
New Business Applications and Supporting Documents FOR USE IN MASSACHUSETTS Point of Sale Support: Enhanced POS Interviews Mon. - Fri. 8:00am-10:00pm E.T. 1-800-358-6337, Opt. 2 Sat. 9:00am-2:00pm E.T.
More informationCritical Illness with Term Assurance
AIG Life Critical Illness with Term Assurance Our comprehensive Critical Illness with Term Assurance delivers more value and quality to the customer and their family than ever before. It is designed to
More informationList of Qualifying Conditions
List of Qualifying Conditions Cancer Conditions 1) Adrenal cancer 2) Bladder cancer 3) Bone cancer all forms 4) Brain cancer 5) Breast cancer 6) Cervical cancer 7) Colon cancer 8) Colorectal cancer 9)
More informationHow To Get A Medical Insurance Policy From Unum
APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Unum Life Insurance Company of America ( Unum ) 2211 Congress Street Portland, Maine 04122 Application Type: Newly Eligible Late
More informationCENTRAL STATES INDEMNITY CO. OF OMAHA Home Office: Omaha, NE Administration: P.O. Box 10816 Clearwater, Florida 33757-8816
CENTRAL STATES INDEMNITY CO. OF OMAHA Home Office: Omaha, NE Administration: P.O. Box 10816 Clearwater, Florida 33757-8816 APPLICATION FOR MEDICARE SUPPLEMENT COVERAGE SECTION A. PROPOSED INSURED INFORMATION
More informationGroup 2: Critical Illness Benefits
Group 2: Zurich s cover is designed to free yourself and your loved ones from the potentially devastating financial impact that follows diagnosis with a critical illness. 1. Level Term Life or Earlier
More informationNOT FOR USE WITH THE PUBLIC. FOR PRODUCER USE ONLY.
ForeCareTM Fixed Annuity Facts and Factors NOT FOR USE WITH THE PUBLIC. FOR PRODUCER USE ONLY. Long-Term Care The Big Picture When you think about long-term care, what picture comes to mind? Do you think
More informationPhoenix Safe Harbor Term Life Express SM
Phoenix Safe Harbor Term Life Express SM Quick Reference Guide For agent use only. Not for distribution to the public as sales literature. Table of Contents Product Overview... 3 Accelerated Benefit Rider
More informationFor intermediary use only not for use with your clients. Medical condition guide
For intermediary use only not for use with your clients Medical condition guide Introduction Listed in this guide are the most common medical disclosures we are asked about. You will find an explanation
More informationCritical illness conditions covered
For financial adviser use Critical illness conditions covered Provider Alzheimer s Disease age 65 age 60 Aorta graft surgery for disease Benign brain tumour Blindness permanent and irreversible Cancer
More informationWe understand you want support right from the beginning
PROTECT We understand you want support right from the beginning PRUearly stage crisis cover Should an illness strike, the earlier it is diagnosed, the easier it is to manage and the higher the chances
More informationDallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
More informationRenews to Age Additional Riders Available Accepted If Following Can Be Answered in Application
Revised July 25, 2013 Company La Capitale Affirmative - Guaranteed Level Whole Life with Cash Value and Reduced Paid Up Values - If death occurs by other than accidental means within the first two years,
More informationAMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224
AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224 For AHL Home Office use only tes EVIDENCE OF INSURABILITY AND ENROLLMENT FORM Check appropriate
More informationCritical Illness Insurance
You ve protected your family s financial future by purchasing life and health insurance. Critical Illness Insurance It s cash when you need it. You choose how to spend it. So you can focus on getting well.
More informationThe insurance company checked above (Company) is responsible for the obligation and payment of benefits under any policy that it may issue.
American International Life Assurance Company of New York* Home Office: 80 Pine Street, New York, NY 10005 The United States Life Insurance Company in the City of New York* Home Office: 830 Third Avenue,
More informationWe have made the following changes to the Critical Illness events covered under our group critical illness policy.
We have made the following changes to the Critical Illness events covered under our group critical illness policy. March 2015 Because everyone needs a back-up plan 7 New critical illness events added to
More informationCovers 60 major critical illnesses. Covers 11 minor critical illnesses. ManuMulti Care
It s a difficult subject to think about, but part of planning for the future is being prepared for the unexpected. Critical illness can happen to anyone, at any time. And it s an unfortunate fact, but
More informationOMIP. Oregon Medical Insurance Pool. Application 2007. We re here for you! 440-3189 (01/07) FOMIP4 (01/07)
OMIP Oregon Medical Insurance Pool Application 2007 We re here for you! 440-3189 (01/07) FOMIP4 (01/07) OMIP Oregon Medical Insurance Pool Application Instructions 1. If you are currently enrolled in OHP/Medicaid
More informationGroup Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance
Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance INSTRUCTIONS - Please print all answers If required, retain a photocopy for your files. 1a) Plan contract number(s)
More informationTHP Insurance Company, Inc. (THP) Medicare Supplement Insurance Policy Application Ohio and West Virginia
Important Notice: Refer to the Guaranteed Issue Guide to determine eligibility for automatic acceptance. If eligible, indicate which situation is applicable in the Guaranteed Issue section. You are not
More informationPersonal Health Insurance Add family member
Personal Health Insurance Add family member Policy 037000 ID number of owner A Plan information Health Coverage Choice (HCC) plan - Only complete section A, B and D. Add my spouse and/or child. I am aware
More informationMedicare Supplement Application Aetna Life Insurance Company Aetna Administrator, P.O. Box 10374, Des Moines, IA 50306
Medicare Supplement Application Aetna Administrator, P.O. Box 10374, Des Moines, IA 50306 INSTRUCTIONS: To be considered complete, all sections on this form must be filled out, unless marked optional.
More informationSingle Premium Whole Life
Secure Solutions Single Premium Whole Life Agent Underwriting and Product Guide The Baltimore Life Insurance Company 10075 Red Run Boulevard Owings Mills, MD 21117-4871 www.baltlife.com For agent use only.
More informationSCP Material ID: 2014_MedSupp_Application. Medicare Supplement Application
Medicare Supplement Application OPEN ENROLLMENT AND GUARANTEED ISSUE PERIOD If any of the following situations apply, applicant is in an open enrollment or guaranteed issue period. ELIGIBILITY FOR OPEN
More informationLIFE BOLD SIMPLE DIFFERENT. A personal approach to life cover LIFE
LIFE SIMPLE BOLD DIFFERENT A personal approach to life cover LIFE ALEXANDER FORBES LIFE Protecting your wealth to secure your financial well-being Flexible, to change as often as life does. You can change
More informationVoluntary Benefits Employee Enrollment and Change Form
LifeMap Assurance Company TM P.O. Box 1271, MS E-3A Portland, OR 97207-1271 (503) 721-7161 (800) 794-5390 Voluntary Benefits Employee Enrollment and Change Form For residents of Oregon and Washington,
More informationFor customers Friends Life Individual Protection Critical Illness Cover. Critical Illness Cover. It s critical illness. And more.
For customers Friends Life Individual Protection Critical Illness Cover Critical Illness Cover It s critical illness. And more. It s critical illness. And 2 it s designed with your needs in mind. it covers
More informationVoluntary Benefits Employee Enrollment and Change Form
Voluntary Benefits Employee Enrollment and Change Form LifeMap Assurance Company TM For residents of Oregon and Washington, the definition of a Spouse includes your legal husband or wife or your State
More informationCritical Illness Supplemental Insurance
You ve protected your family s financial future by purchasing life and health insurance. Critical Illness Supplemental Insurance It s cash when you need it. You choose how to spend it. So you can focus
More informationAccelerated Protection. Do I need Critical Illness insurance?
Accelerated Protection Do I need Critical Illness insurance? Are you prepared? It s a fact of life that we all get sick, and sometimes seriously. The cost of recovery from an illness like cancer or heart
More informationN Basic, including 100% Part B coinsurance. Basic including 100% Part B coinsurance* Basic including 100% Part B coinsurance
HEARTLAND NATIONAL LIFE INSURANCE COMPANY Outline of Medicare Supplement Coverage Benefit Plans A, D, F, G, M and N Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After Jun 1,
More informationAPPLICATION FOR FINAL EXPENSE WHOLE LIFE
APPLICATION FOR FINAL EXPENSE WHOLE LIFE SBLI USA Life Insurance Company, Inc. Toll Free: 1-877-SBLI-USA / 1-877-725-4872 460 W. 34th Street, Suite 800, New York, NY 10001-2320 website: www.sbliusa.com
More information