APPLICATION FOR TERM CONVERSION (with Riders or Extra Benefits) OR POLICY REISSUE

Transcription

1 APPLICATION FOR TERM CONVERSION (with Riders or Extra Benefits) OR POLICY REISSUE Liberty National Life Insurance Company P.O. Box 2612 Birmingham, AL A Nebraska Stock Company PART 1 Section A Policy Number Print first, middle, and last names of Primary Insured Family Group Address: No. and Street City or Town State Zip Please attach policy (if available) Convert term coverage at attained age on life of: Plan: Amount: If this is a conversion of a term rider, the basic policy is to be Continued Cancelled, and any cash value paid to me If all of the term insurance is not to be converted, the balance is to be continued cancelled If additional insurance is desired, enter amount of new insurance $ If this is a conversion of Group Term Life, are you eligible for any other group life insurance Yes No Amount: $ If this is a conversion of a child rider, the rider is to be continued cancelled If this is a conversion of a child rider, list child s Name: Sex: and Date of Birth Exchange permanent coverage at original age on the life of Plan: Reduce amount of insurance to $ Plan: Remove or reduce extra rating Reinstate and redate (collect one mode premium) Other changes: PART 1 Section B Complete this section if adding or deleting coverage or benefits Additional benefit requests below apply to basic policy; new policy issued as a result of conversion requests or exchange made above. Add Delete Add Delete PW Term Rider: Plan $ ADB Spouse Coverage: Plan $ With ADB Children s Insurance: $ With ADB Other: PART 1 Section C Beneficiary Relationship to Proposed Primary Insured Contingent Beneficiary Relationship to Proposed Primary Insured PART 1 Section D Method of Payment Requested on New Policy A SA Q MN GA BB (Comp. Authorization for Pre-Authorized Payments) PD (Attach Authorization if required) WD LNL Employee # If PD Selected complete Franchise No. Cafeteria Plan: Yes No Requested Effective Date: / / Payroll Deduction Frequency: Weekly Bi-Weekly Semi-Monthly Monthly Automatic Premium Loan, if available. Yes No

2 PART 2 COMPLETE THIS SECTION IF Additional insurance is desired (adding coverage on the primary insured, spouse or child) 1. Proposed Insured (First, middle, & last) D.O.B Age Birthplace Height Weight Sex Marital Status M M F S 2. Drivers License # State 3. SS# of Proposed Insured 4. Employer s Name 5. Occupation/Duties 6. Spouse (First, middle, & last) Maiden Name D.O.B. Age Birthplace Height Weight Sex M F 7. Drivers License # State 8. SS# of Proposed Insured 9. Employer s Name 10. Occupation/Duties Child s Name (First, middle, & last) Relationship to Primary Insured Birth date Mo./Day/Yr. Sex Social Security No. 16. Total Life Insurance in Force on each Proposed Insured Proposed Insured No. Company Face Amount ADB Amount Height ft. In. Weight lbs.

3 Adding coverage or benefits on primary insured, spouse or child (questions should be answered for each proposed insured) PW Benefits are included in the base policy and you are applying for additional coverage on the spouse or child (questions should be answered for the primary insured as well as the spouse or child) 1. Are all proposed insured(s) citizens of the United States? (If no complete and attach A-282-2)... Yes No 2. Has any proposed insured ever been rejected for life insurance, rated, or failed to receive a policy as applied for?... Yes No 3. Has any proposed insured ever had, been treated for, or advised to be treated for any of the following conditions: (a) High blood pressure, chest pain, heart attack, stroke or any heart or circulatory disorder?... Yes No (b) Asthma, emphysema, or other respiratory disorder?... Yes No (c) Ulcer, colitis, or other digestive tract disorder?... Yes No (d) Cirrhosis, hepatitis, or other liver disorder or any blood disorder?... Yes No (e) Diabetes or other endocrine disorder?... Yes No (f) Kidney, prostate, urinary, bladder or other genitourinary disorder?... Yes No (g) Paralysis, epilepsy, mental disease or disorder or any other nervous system, brain disorder or psychological disorder?... Yes No (h) Cancer, tumor, or unexplained masses?... Yes No (i) Disease of the breasts, uterus, or ovaries?... Yes No (j) Rheumatoid arthritis or any musculoskeletal disorder?... Yes No (k) Alcoholism or alcohol abuse including membership in A.A. or been advised by a physician to reduce alcohol consumption?... Yes No (l) Impairment of sight or hearing?... Yes No 4. Has any proposed insured ever tested positive for exposures to the Human Immunodeficiency Virus (HIV) infection or been diagnosed, by a member of the medical profession, as having Aids Related Complex (ARC) or Acquired Immune Deficiency Syndrome (AIDS) caused by the Human Immunodeficiency Virus (HIV) infection or other sickness or condition derived from such infection?... Yes No 5. Has the proposed insured ever applied for or received disability or workers compensation based on permanent disability or is currently receiving government, workers compensation or disability policy benefits for temporary disability?... Yes No PART 3 THIS SECTION SHOULD BE COMPLETED IF Requesting that extra rating be removed or reduced; or exchanging to a plan with a lower premium rate per unit of coverage (questions should be answered for the primary insured or the spouse, if applying for reduction on spouse coverage) Requesting reinstate and redate (questions should be answered for the primary insured) 6. Has any proposed insured in the last five years: (a) Had a physical examination?... Yes No (b) Had any medical treatment? (including prescription medications)... Yes No (c) Been hospitalized?... Yes No (d) Any other illness, injury or operation?... Yes No 7. Has any proposed insured ever used alcohol to excess or used narcotics, sedatives, or hallucinogens?... Yes No 8. Has any proposed insured used marijuana in the past year?... Yes No 9. Has any proposed insured ever been arrested, including arrests for driving while intoxicated or under the influence?... Yes No 10. Does any proposed insured smoke cigarettes or use tobacco in any other form?... Yes No 11. If a former user of tobacco, when did proposed insured quit? Date... Yes No Answer if face amount is $100,000 and above. 12. Has any proposed insured within the last two years made or intend to make any flights other than as a passenger on a scheduled airline?... Yes No 13. Has any proposed insured within the last two years engaged in or intend to engage in automobile, motorboat, or motorcycle racing, scuba, skin or sky diving?... Yes No 14. Does any proposed insured plan to travel or reside outside the United States or Canada within the next year?... Yes No Answer question 15 if this application is taken in a state that has adopted the 1998 Model Replacement Regulation. 15. Does any proposed insured have existing life insurance or annuities in force, including policies under conditional receipt, other than Group or Credit Life Insurance with this or any other company? If Yes comply with the applicable replacement regulation... Yes No If questions 2-14 are answered Yes, give explanations, dates, names and addresses of physicians & hospital (if any) below. Proposed Ques. Insured No. no. Explanation Date Hospital Duration Physician Address

4 Declaration and acknowledgement and Authorization to Obtain and Disclose Information The policy changes herein requested shall not be effective until the application is approved, policy delivered, and any necessary payment has been received by the Company. In any new policy issued at the attained age of the Insured on the basis of this application, the effective date referred to in the Incontestability and Suicide provisions of the new policy shall be the effective date of the original policy, except as pertains to the increased portion of the new face amount and extra benefits included in the new policy, for which the effective date shall be the effective date of the new policy. The acceptance of any policy issued pursuant to this application 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. I hereby declare that the statements recorded herein are true and complete. I understand that no agent has authority to accept risks or make or change contracts or waive the Company s right or requirements. Except with respect to a minor child of mine, this application is made with the knowledge and consent of the proposed insured. I understand and agree that the Company reserves the right during the first year the policy is in force, to restrict beneficiaries to designations acceptable to the Company in its sole discretion. I state that the answers set forth herein, are full, complete and true. The answers are to be the basis of any insurance issued. I also acknowledge that I have received the Investigative Consumer Reports Notification and MIB notice attached to this application. In order to evaluate my application for insurance, I understand Liberty National Life Insurance Company ( the Company or Liberty National ) and its reinsurers may obtain medical records, attending physician s statements, and other information as specified below, as well as seeking clarification of application information by telephone interview. This information may be acquired from any of your treating physicians or medical practitioners, as well as hospitals, clinics, medically related facilities, the Veterans Administration, MIB, Inc. or any consumer reporting agency, or any insurance company that has any records or knowledge of me or my health (except for psychotherapy notes). The information may include any care, treatment or advice provided to me. This includes records relating to alcohol or drug abuse, mental disease or information concerning a condition which may be considered a communicable or venereal disease which may include, but are not limited to, diseases such as Hepatitis, Syphilis, Gonorrhea and the Human Immunodeficiency Virus, also known as Acquired Immune Deficiency Syndrome (AIDS). Liberty National may report such information to MIB, Inc. or to other insurance companies to which I have applied or may apply. In addition, we may obtain the applicant s driving history from the Department of Motor Vehicles and criminal record. The Company reserves the right to request and obtain information and clarification of the applicant s financial situation, the relationship of the beneficiary to the Proposed Insured, as well as additional information pertaining to the policy owner. This authorization will be valid for 24 months from the date of signature. A photocopy of this authorization will be as valid as the original. I, or my authorized representative may receive a copy of this authorization upon request. Important Notice: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. Signed at City State Date Signature of Spouse if Adding or Changing Spouse Coverage Signature of Proposed Insured / Applicant Witness Signature of Agent Signature of Owner (Federal law requires the following notice: We may request or obtain additional information to establish or verify your identity.)

5 AGENT S STATEMENT AGENT S REMARKS I personally saw did not see each proposed insured. Those not seen are listed under Agent Remarks. To the best of my knowledge and belief, the insurance is is not intended to replace any insurance now in effect. Is the proposed insured covered under one or more existing life insurance policies or annuities in force, including policies under conditional receipt, with any insurance company? Yes No I personally witnessed all signatures. Yes No Do you have any reason to believe that any response to the questions on this application are not accurate? Yes No Signature of Agent Agent s Name (Please Print) Agent Number / / Branch Agency Client No. Telephone Numbers / Information Yes No Home: During Day Business: Extension During Day Cell Phone: During Day Address: Is it satisfactory to contact other adult family members? Yes No Most convenient time and place for interview call: Home Office Preferred Time: A.M. P.M. LNL

6 NOTICE REGARDING MIB, INC. Information regarding insurability will be treated as confidential. Liberty National Life Insurance Company or its reinsurers may, however, make a brief report thereon to MIB, Inc., formerly known as the Medical Information Bureau, a not-for-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request will supply such company with the information about you in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at (TTY ). If you question the accuracy of information in MIB s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB s information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts Liberty National Life Insurance Company or its reinsurers may also release information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at NOTICE TO PERSONS APPLYING FOR INSURANCE As part of our procedure for processing your insurance application, an investigative consumer report may be prepared whereby information is obtained through personal interviews made by a consumer reporting agency with you, your family, neighbors, friends and others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics and mode of living. In addition, physicians, hospitals, clinics and other medically-related facilities may be contacted, using your signed authorization, to obtain details of your past medical treatment. You have the right to be interviewed as a part of any investigative consumer report that may be prepared. If you desire to be interviewed, you should indicate this in the space provided on this form. You also have the right of access, correction and amendment with respect to any personal information collected. Upon your request, you are entitled to receive a description of procedures which allow access to and correction of personal information which may be obtained, a description of the circumstances under which personal information may be disclosed without prior authorization or a copy of the report, and a summary of your rights under the Federal law regarding any such report. Your written request should be addressed to Liberty National Life Insurance Company, P.O. Box 2612, Birmingham, Alabama