MORTGAGE PROTECTION PLANS to meet your needs and budget. OPTION 1 OPTION 2
|
|
- Clara Bates
- 8 years ago
- Views:
Transcription
1 FIRST SERVICE CORPORATION Summary of MORTGAGE PROTECTION PLANS to meet your needs and budget. OPTION 1 OPTION 2 Value Priced - Mortgage Life Rates favor non-tobacco users Non-Tobacco & Tobacco user rates. Pays off scheduled insured balance of the loan up to the plan maximum if insured dies from any cause, except suicide within 2 years from the issue date. 1 or 2 borrowers can apply. 2-in-1 Life Plus Limited Benefit Life Death by NATURAL causes: Pays 24 Monthly Benefit Payments. Death by ACCIDENTAL causes: Pays off scheduled mortgage balance up to $100,000 PLUS 24 monthly benefit payments to survivors. Same low rate for all ages. OPTION 3 OPTION 4 Accidental Death Death from ACCIDENTAL causes - Pays off scheduled loan balance up to the plan maximum. Guaranteed Acceptance - No Health Questions Mortgage Disability Pays monthly benefit payments if work is missed due to a covered Sickness or Injury after 30 days of continuous disability. For a catalogue with complete information and an application, contact the mortgage department of your lender or call our insurance administrator, First Service Corporation, at either of the telephone numbers below. FIRST SERVICE CORPORATION Harper Avenue - Harper Woods, MI or info@fscinsurance.com Monday thru Friday - 9:00 am to 5:00 pm EST ND110-2
2 OPTION 1 MORTGAGE LIFE INSURANCE Benefits based on insurance amount at date of death OPTION 2 2 in 1 LIFE PLUS Limited Benefit Mortgage Life Insurance Single or Joint Coverage Available Partial Coverage Available Maximum Coverage $300,000 Minimum Coverage $10,000 Personal guarantor eligible for corporate loans One exclusion: Suicide first 2 years from coverage start date Premiums do not increase as you grow older Maximum eligible age: Thru age 69 Termination age: Age 75 Example: How to figure your monthly premium One person age 29, non-smoker Insurance $100, x $.12 = $12.00 Single Life Rates per $1000 per Month Age Non-Smoker Smoker Under 30 $0.12 $ $0.16 $ $0.20 $ $0.30 $ $0.46 $ $0.66 $ $0.96 $ $1.50 $ $2.38 $4.06 Joint coverage: Use age of older borrower. If either person has used tobacco in the last 12 months, regardless of age, use older person s Tobacco Rate. Joint Life Rates per $1000 per Month Age Non-Smoker Smoker Under 30 $0.18 $ $0.24 $ $0.30 $ $0.45 $ $0.69 $ $0.99 $ $1.44 $ $2.25 $ $3.57 $6.09 An inexpensive program to help your survivors adjust to losing you and your income but not losing their home HOW THIS PLAN PAYS BENEFITS IF DEATH BY ILLNESS, SICKNESS OR DISEASE Pays 24 monthly benefit payments to your mortgage lender giving survivors time to decide what to do with the house IF DEATH BY ACCIDENTAL CAUSES Pays off scheduled mortgage balance up to $100, PLUS Pays 24 monthly benefit payments to your survivors One or two borrowers eligible to apply Second borrower premium is discounted Choose the monthly benefit you want up to your monthly mortgage payment Maximum monthly benefit $2,000 Minimum monthly benefit $200 Personal guarantor eligible for corporate loans Premiums do not increase as you grow older Maximum entry age: Thru age 65, Coverage ends at 70 Same premium rate for all ages. Premium based on monthly benefit you choose, NOT on your loan balance or age Monthly Premium is a percentage of the monthly benefit you choose One Person - 2.5%, Two People - 4.0% HOW TO FIGURE YOUR PREMIUM Example: Monthly Benefit Chosen $600 One person: $600 x 2.5% = $15.00 Two persons: $600 x 4% = $24.00
3 MORTGAGE ACCIDENTAL DEATH Pay off mortgage loan balance for death by accident An accidental death is one that results from an external bodily injury that occurs unexpectedly and suddenly without the insured person s intent but includes smoke inhalation and drowning. No health questions or physical exams Eligibility: Everyone under age 70 automatically qualifies Coverage ends at age 75 Insure the whole mortgage balance or any part of it. One or Two borrowers can be insured for their loan Premium discount for second insured Personal guarantor eligible for corporate real estate loans Maximum coverage $300,000 Monthly rates per $1,000: One borrower.20 Two borrowers.30 The following are examples of an accidental death: 1. Drowning 2. Accidental smoke inhalation 3. Choking on gum or food 4. Motorcycle accidents 5. Gun shot wound 6. Accidental hanging 7. Electrocution 8. Commercial airline crash EXCLUSIONS OPTION 3 9. Pedestrian hit by an automobile 10. Farm tractor overturn 11. Kitchen grease fire 12. Crushed by a falling tree 13. Hunting accidents 14. Stab wound 15. Bath tub accidents This coverage does not pay for the death of any Insured Mortgagor caused by or contributed by, or as a consequence of or resulting from: (1) suicide or any attempted suicide while sane or insane; (2) sickness or disease of any kind; (3) bacterial infections, except pyogenic infections, which shall occur through an accidental cut or wound; (4) injury sustained in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a passenger, pilot or crew member of a regularly scheduled commercial aircraft used for the transportation of passengers; (5) declared or undeclared war and any act thereof; (6) service in the military, naval or air service of any country; (7) hernia; or (8) narcotics or drugs, except when administered on the advice of a physician. (See an insurance certificate for specific details.) MORTGAGE DISABILITY INSURANCE HOW THIS INSURANCE PLAN WORKS FOR YOU Your total monthly disability benefit payment will be the amount you apply for on your application for coverage. However, it cannot exceed the total amount of your monthly mortgage payment at the time you apply or the maximum noted below. INSURANCE DEFINITION OF BEING DISABLED You are considered totally disabled when you are under a doctor s regular care for an injury or illness other than mental, emotional, or nervous disorders; alcoholism; or drug addiction (subject to policy exclusions) that prevents you from performing the substantial duties of your occupation Coverage available for one or two mortgagors. Eligibility ages 18 thru 60 Coverage ends at 65 Maximum monthly benefit $1,500 Benefits begin after 30 days of continuous disability, starting with the 1st day. 1/30th of the insured benefit will be paid for each successive day of disability while under a doctor s care. The maximum benefit for each separate disability is 12 monthly insured benefit payments. Payments do not continue after your mortgage is paid-in-full or otherwise discharged. The monthly premium is based on a percentage of the monthly benefit to be insured. Age: Monthly Rate: 3.50% 4.00% 6.50% 9.00% EXAMPLE: AGE 35 BENEFIT $ Monthly Rate Total Monthly Mortgage Payment Monthly Cost 4.00% X $ = $20.00 EXCLUSIONS OPTION 4 There is no coverage for any disabilities caused by pregnancy or childbirth; elective abortion; intentionally self-inflicted injury; active participation in a riot; participation in the commission of a felony; flight in any device for aerial navigation other than as a passenger on an airplane operated by a government authorized commercial airline regularly flying scheduled routes; mental, emotional or nervous disorder; alcoholism or drug addiction; war or act of war, declared or undeclared. In addition if you have received medical advice, consultation or treatment for a sickness, disease or physical condition within 12 months before your enrollment, you are not covered for a disability due to that specific condition unless the disability occurs after you have been insured for 12 months or while receiving unemployment compensation from any State or Government related agency.
4 Administrative Office: Prairie Village, Kansas GROUP INSURANCE APPLICATION TO INDIVIDUAL ASSURANCE COMPANY, LIFE, HEALTH & ACCIDENT PLEASE PRINT BE SURE ALL QUESTIONS ARE ANSWERED NAME MORTGAGOR #1 NAME MORTGAGOR #2 #1 APPLYING FOR: MORTGAGE LIFE ACCIDENTAL DEATH #2 APPLYING FOR: MORTGAGE LIFE ACCIDENTAL DEATH 2-IN-1 LIFE PLUS DISABILITY Mo. Payment $ 2-IN-1 LIFE PLUS DISABILITY Mo. Payment $ MAILING ADDRESS - NUMBER & STREET MAILING ADDRESS - NUMBER & STREET CITY - STATE - ZIP CODE CITY - STATE - ZIP CODE TELEPHONE NUMBER TELEPHONE NUMBER HOME: ( ) CELL: ( ) HOME: ( ) CELL: ( ) ADDRESS (IF ADDITIONAL INFORMATION IS NEEDED) ADDRESS (IF ADDITIONAL INFORMATION IS NEEDED) DATE OF BIRTH AGE STATE OF BIRTH HEIGHT WEIGHT DATE OF BIRTH AGE STATE OF BIRTH HEIGHT WEIGHT FT. IN. LBS. FT. IN. LBS. OCCUPATION DESCRIBE DUTIES OCCUPATION. DESCRIBE DUTIES SECOND BENEFICIARY NAME RELATIONSHIP SECOND BENEFICIARY NAME RELATIONSHIP 1. To the best of your Knowledge or belief have you within the last (5) years have you been treated for or diagnosed as having Heart Trouble; Diabetes; Tumor; Cancer; High Blood Pressure; A Mental Disorder; Epilepsy; Rheumatic Fever; Alcoholism; Drug Addiction; Disorder of the Lungs; Stomach; Liver; Kidneys; Brain; Stroke; Nervous System; Back; Neck; Joints; or Acquired Immune Deficiency Syndrome (AIDS); AIDS Related Complex (ARC); or HIV Positive? YES NO If Yes circle condition(s) above and give details below 2. During the last (5) years have you consulted any doctor or other medical facility for any illness, injury or any other physical condition other than disclosed in 1 above? YES NO If YES give details below 4. Have you used tobacco in the last 12 months? YES NO 5. ANSWER THIS QUESTION IF APPLYING FOR DISABILITY: Are you now employed outside your home and regularly working in the occupation shown above on the basis YES NO of 30 hours or more per week or more? If NO explain in space below 1. To the best of your Knowledge or belief have you within the last (5) years have you been treated for or diagnosed as having Heart Trouble; Diabetes; Tumor; Cancer; High Blood Pressure; A Mental Disorder; Epilepsy; Rheumatic Fever; Alcoholism; Drug Addiction; Disorder of the Lungs; Stomach; Liver; Kidneys; Brain; Stroke; Nervous System; Back; Neck; Joints; or Acquired Immune Deficiency Syndrome (AIDS); AIDS Related Complex (ARC); or HIV Positive? YES NO If Yes circle condition(s) above and give details below 2. During the last (5) years have you consulted any doctor or other medical facility for any illness, injury or any other physical condition other than disclosed in 1 above? YES NO If YES give details below 4. Have you used tobacco in the last 12 months? YES NO 5. ANSWER THIS QUESTION IF APPLYING FOR DISABILITY: Are you now employed outside your home and regularly working in the occupation shown above on the basis YES NO of 30 hours or more per week or more? If NO explain in space below If you have answered Yes to question 1 or 2 or if you have answered No to question 5, give details below. USE REVERSE SIDE IF MORE SPACE IS NEEDED. Ailment Treatment Dates Medications Ailment Treatment Dates Medications Doctor's name Complete mailing address Doctor's name Complete mailing address Tel. No. ( ) Fax No. ( ) Tel. No. ( ) Fax No. ( ) All answers are true and complete to the best of my knowledge. To determine my insurability, or for claim purposes, I authorize any medical practitioner, insurance company, the Medical information Bureau, Inc., or a consumer reporting company to release any information about me or my physical or mental condition (including drug or alcohol abuse) to underwriting, medical or other representative of the insurance company shown at the top of this application. I understand that information will not be given to any person or organization except the following: reinsurers; the Medical Information Bureau, Inc.; or any other people or organizations who perform business or legal service in connection with this Application. This authorization is valid for 30 months from the date I sign it. A photocopy may be used as a legal document. I know that a consumer report may be needed to complete the processing of this Application. I may ask to be interviewed and to have this interview be used as part of this report. If I ask for it in writing, I may receive a copy of the report. I authorize my lender to collect the appropriate insurance premium(s) in accordance with its usual procedure. I have read this authorization and the Consumer Privacy Notice attached and understand that I or my representative can have copies. I have read and kept the brochures accompanying this form. THE FOLLOWING APPLIES ONLY TO DISABILITY COVERAGE: I UNDERSTAND THAT THE COVERAGE APPLIED FOR WILL NOT PAY BENEFITS FOR ANY LOSS INCURRED DURING THE FIRST TWELVE MONTHS AFTER THE ISSUE DATE CAUSED BY A DISEASE OF PHYSICAL CONDITION FOR WHICH I RECEIVED MEDICAL TREATMENT OR ADVICE DURING THE 12 MONTHS IMMEDIATELY PRIOR TO THE EFFECTIVE DATE OF THIS COVERAGE. X X Signature - Mortgagor #1 Date Signature - Mortgagor #2 Date MASTER POLICYHOLDER - CREDITOR-BENEFICIARY FOR INSURANCE INFORMATION CONTACT: Meijer Credit Union ACH FIRST SERVICE CORPORATION HARPER AVENUE HARPER WOODS, MICHIGAN (313) or Toll-Free GROUP # FS INFO@FSCINSURANCE.COM FSC 2008 THIS SECTION TO BE COMPLETED BY MORTGAGE LENDER MORTGAGEE Loan OFFICER LOAN NO. DATE LOAN NEW LOAN EXISTING LOAN I.D. OPENED TERM INITIAL CURRENT TOTAL REFINANCED FROM REMAINING INTEREST LOAN $ LOAN PAYMENT $ LOAN NO. MOS. RATE % BALANCE INCLUDING ESCROW COVERAGE(S) & AMOUNT DESIRED MORTGAGE LIFE (VALUE PRICED) 2 IN 1 LIFE PLUS ACCIDENTAL DEATH DISABILITY MORTGAGOR #1 $ $ BENEFIT $ $ MORTGAGOR #2 $ $ BENEFIT $ $ BENEFIT BENEFIT NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person files an application for insurance containing any materially false, incomplete or misleading information, or conceals for the purpose of misleading. Information concerning any fact material thereto, is guilty of insurance fraud, which is a crime and may subject such person to civil and/or criminal penalties. IAC MC-1018 MI (REV 03 09)
5
T his document Contains a selection of Insurance
Mortgage Protection Insurance Available to our Borrowers T his document Contains a selection of Insurance plans to meet the needs and budget of every real estate mortgagor. The following pages describe
More informationYou may apply for up to $2,000,000. Your spouse may apply for up to $1,000,000
ASSOCIATION LIFE INSURANCE THROUGH THE ISBA INSURANCE AGENCY Thank you for your interest in the ISBA s Group Term Life Insurance product. Per your request, please find enclosed the following: A product
More information2 SPOUSE COVERAGE: Add Drop Increase Decrease Note: Spouse coverage amount may not exceed the employee coverage amount under this program.
Group Universal Life (GUL) Program Change Form Group Name Clackamas County GUL# 74414 Work Location (City, State, Zip) 2051 Kaen Rd, Suite 310, Oregon City, Oregon, 97045 Employee Social Security # Daytime/Work
More informationEvidence of Insurability
GROUP INSURANCE The Prudential Insurance Company of America Evidence of Insurability Instructions for Employer/Association 1. Complete the form below. 2. Also complete all sections of the form noted Part
More informationEvidence of Insurability
GROUP INSURANCE The Prudential Insurance Company of America Evidence of Insurability Instructions for Employer/Association 1. Complete the form below. 2. Also complete all sections of the form noted PART
More informationWelcome to Credit Union-Approved 50-Plus Term Life Insurance
Welcome to Credit Union-Approved 50-Plus Term Life Insurance Print out this kit for everything you need to decide if this coverage is right for you: 50-Plus Term Life Insurance introduction and highlights
More informationEmail Address: _ Pre-Disability Earnings: $ City: State: Zip Code: Beneficiary Print full name & relationship to you
GROUP DISABILITY INCOME INSURANCE APPLICATION HARTFORD LIFE INSURANCE COMPANY Simsbury, Connecticut 06089 Policyholder: (Participating Organization) Policy No.: Certificate No.: (Leave Blank) AGP-5697
More informationFamily Life Insurance Company LBS. Living Benefit Series. Critical Choice LBS. Living Benefit Series. Agent Guide AGT-VL/VCC 0314
Family Life Insurance Company LBS Living Benefit Series Critical Choice LBS Living Benefit Series AGT-VL/VCC 0314 Agent Guide Table of Contents Product Specifications - Viva Life Life Insurance Benefit....
More informationPublic Employees' Retirement System of Mississippi Brings You: Group Term Life Insurance
Public Employees' Retirement System of Mississippi Brings You: Group Term Life Insurance What is it, what does it cover, how can you apply? Answers to your questions about your PERS insurance plan About
More informationMetropolitan Life Insurance Company Statement of Health Form
Metropolitan Life Insurance Company Statement of Health Form Instructions for Completing Statement of Health Form A separate Statement of Health form is required for each Proposed Insured requesting insurance.
More informationNEXT PAGE. Applicant information (Please print or type) Name. Are you a: Member Spouse Domestic Partner* If Spouse/Domestic Partner, Name of Member
APPLICATION FOR GROUP LEVEL TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Applicant information (Please print or type)
More informationAPPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company)
APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Member information (Please print or type) Name APTA
More informationMetropolitan Life Insurance Company Statement of Health Form
Metropolitan Life Insurance Company Statement of Health Form Instructions for Completing Statement of Health Form A separate Statement of Health form is required for each Proposed Insured requesting insurance.
More informationA Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form
A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself
More informationAPPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company)
APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Member information (Please print or type) Name APTA
More informationSimple, Affordable & SAFE!
California State Firefighters Employee Welfare Benefits Corporation Simple, Affordable & SAFE! Limited Time Simplified Issue Offer Group Term Life Insurance Application (10-Year Level Term Rate) C2 ReliaStar
More informationA Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form
A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself
More informationMember s Name Social Security # First Middle Last. Member s Address Number Street City State Zip Code. Name and Address of Member s Physician
Please print or type all information requested Member s Name Social Security # First Middle Last Member s Address Number Street City State Zip Code ASRT Member ID # Home Phone No. Work Phone No. Name and
More informationCompleting your Personal Health Application New York Applicants
Completing your Personal Health Application New York Applicants Purpose These instructions will help you to complete your Personal Health Application. This will help ensure that your application is processed
More informationUSLIFE Group Voluntary Term Life Insurance Coversheet
USLIFE Group Voluntary Term Life Insurance Coversheet Applicant Name: (If applicable see next section below) NYSBG Company Name: NYSBG Dues Level: Corporate $60 Current Check attached Corporate Employee
More informationA Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form
A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself
More informationHARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut 06089 Section 1
GROUP LIFE INSURANCE APPLICATION HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut 06089 Section 1 Policyholder: American College of Emergency Physicians Policy No.: AGL-1905 Certificate
More informationGROUP DISABILITY INCOME INSURANCE ENROLLMENT
GROUP DISABILITY INCOME INSURANCE ENROLLMENT Policy Number 01-016542-00 TO BE COMPLETED BY THE POLICYHOLDER Employer/Policyholder Name School Board of Okaloosa County Symetra Life Insurance Company 777
More informationThe United States Life Insurance Company in the City of New York Home Office: One World Financial Center, 200 Liberty Street, New York, New York 10281
The United States Life Insurance Company in the City of New York Home Office: One World Financial Center, 200 Liberty Street, New York, New York 10281 (Herein called the Company) Application For Group
More informationSimple, Affordable & SAFE!
The Insurance & Benefits Trust of PORAC Simple, Affordable & SAFE! Group Term Life Insurance Application (10-Year Level Term Rate) Group Term Life Application for 10-Year Level Term Rate Reference to Spouse
More informationThe United States Life Insurance Company in the City of New York
Are you a: Member Spouse of a Member Member/Applicant information Please print or type Name (First, Middle, Last) Address The United States Life Insurance Company in the City of New York Application For
More informationWelcome to Credit Union-Approved Group Term Life Insurance
Welcome to Credit Union-Approved Group Term Life Insurance Print out this kit for everything you need to decide if this coverage is right for you: Up to $125,000 Group Term Life Insurance for credit union
More informationA Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form
A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself
More informationCheck Life Insurance plan(s) desired Life Insurance for Member: $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000
The United States Life Insurance Company in the City of New York APPLICATION FOR GROUP TERM LIFE INSURANCE Home Office: One World Financial Center, 200 Liberty Street, New York, NY 10281 (Herein called
More informationAmerican General Life Insurance Company Houston, Texas
Application for Life Insurance American General Life Insurance Company Houston, Texas Administrative Office: Mail Stop 6-G2, P.O. Box 4373, Houston, TX 77210-9739 Phone: 866-242-2737 Fax: 713-831-3249
More informationVoluntary Group Term Life Insurance
0159297 Voluntary Group Term Life Insurance American Foreign Service Protective Association Voluntary Group Term Life Insurance Plan Up to $600,000 of Coverage Protect the Ones You Love Whatever is next
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 informationYou never know what can happen on your shift. Is your family financially secure?
You never know what can happen on your shift. Is your family financially secure? Benefits Division Group Life Insurance and Accidental Death Insurance The California State Firefighters Employee Welfare
More informationEvidence of Insurability
GROUP INSURANCE The Prudential Insurance Company of America Evidence of Insurability Instructions for Employer/Association 1. Complete the form below. 2. Also complete all sections of the form noted PART
More informationGroup Term Life Insurance Portability Election Form
Group Term Life Insurance Portability Election Form If you have been actively employed prior to leaving your employer, and you are not retiring or disabled, you may apply for Group Term Life Insurance
More informationThe United States Life Insurance Company in the City of New York
Applicant information (Please print or type) The United States Life Insurance Company in the City of New York APPLICATION FOR GROUP LEVEL TERM LIFE INSURANCE Home Office: One World Financial Center, 200
More informationGROUP TERM LIFE INSURANCE
EXCLUSIVE MEMBER BENEFIT! GROUP TERM LIFE INSURANCE for Pennsylvania Bar Association Members, their Families and their Employees Nothing can replace the loss of a loved one, but carefully chosen life insurance
More informationA Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form
A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. So that we can
More informationSubsequent Election for Payment Protection. Member Name (please print) Date of Birth. Co-Borrower Name Date of Birth. Your Credit Union Account Number
5910 Mineral Point Rd, Madison WI 53705-4456 Phone: 1-800-356-2644 Website: www.cunamutual.com America First Credit Union CUNA Mutual Group Number: 143-0021-7 *IN ISA* *IN ISA* Subsequent Election for
More informationVoluntary Group Accidental Death & Dismemberment Insurance
Voluntary Group Accidental Death & Dismemberment Insurance 0159298 American Foreign Service Protective Association Voluntary Group Accidental Death & Dismemberment Insurance Plan Protect the Ones You Love
More informationSimple, Affordable & SAFE!
The Insurance & Benefits Trust of PORAC Simple, Affordable & SAFE! Group Term Life Insurance Application (5-Year Age Banded Rates, 10 & 20-Year Group Level Term Rates) P-01_06/12 ReliaStar Life Insurance
More informationMONTHLY PREMIUM LIFE AND DISABILITY (SINGLE OR JOINT) CREDIT INSURANCE APPLICATION AND CERTIFICATE (PART A)
MONTHLY PREMIUM LIFE AND DISABILITY (SINGLE OR JOINT) CREDIT INSURANCE APPLICATION AND CERTIFICATE (PART A) SCHEDULE OF CREDIT INSURANCE Credit Union/Primary Beneficiary Educational & Governmental EFCU
More informationHELP PROVIDE SECURITY AT AFFORDABLE RATES
US Airways Pilots Association (USAPA) Group Term Life Insurance 10-Year Level Premium Administered by: For Association Members and Their Families Issued by ReliaStar Life Insurance Company, a member of
More informationCivil Service Employees Benefit Association 67182-7. Address City State Zip. Place of Birth Home/Cell Phone # Work Phone # E-mail Address
Group Term Life Application for 10-Year or 20-Year Level Term Rate Please complete the entire application. If completing this application in paper format, please print clearly in dark ink and mail to WrightUSA
More informationThe United States Life Insurance Company in the City of New York
Member information (Please print or type) The United States Life Insurance Company in the City of New York APPLICATION FOR GROUP TERM LIFE INSURANCE Home Office: One World Financial Center, 200 Liberty
More informationU.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY #
U.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY # POLICY OWNER HOME PHONE INSURED HEIGHT WEIGHT DATE OF BIRTH SOCIAL SECURITY NO. WORK PHONE PLEASE NOTE ANY CHANGE OF
More informationPilot s Disability Insurance
Pilot s Disability Insurance Temporary Loss of License Disability Insurance for People Who Fly For a Living Commercial Pilots Corporate Pilots Cargo Pilots Aerial Applicators Agricultural Pilots Firefighter
More informationGroup Term Life Insurance Portability Election Form
Group Term Life Insurance Portability Election Form If you have been actively employed prior to leaving your employer, and you are not retiring or disabled, you may apply for Group Term Life Insurance
More informationPilot Extended Long Term Disability Insurance
Harvey Watt AirHealth Plans Pilot Extended Long Term Disability Insurance Symetra Life Insurance Company These options are designed to provide extended disability income protection after your Harvey Watt
More informationGroup Disability Income Insurance Enrollment at a Glance Protection that provides benefits and access to expert resources during a difficult time.
Group Disability Income Insurance Enrollment at a Glance Protection that provides benefits and access to expert resources during a difficult time. For the employees of: Shelby County Government What is
More informationSCHEDULE OF PREMIUM AND BENEFITS EFFECTIVE DATE GROUP POLICYHOLDER GROUP POLICY NO. APPLICATION NO. INPAP
AMERICAN MODERN LIFE INSURANCE COMPANY A Stock Company 7000 Midland Blvd, Amelia, OH 45102-2607 SCHEDULE OF PREMIUM AND BENEFITS EFFECTIVE DATE GROUP POLICYHOLDER GROUP POLICY NO. APPLICATION NO. INPAP
More informationVOLUNTARY GROUP TERM LIFE INSURANCE:
VOLUNTARY GROUP TERM LIFE INSURANCE: This plan offers you and your dependents an excellent opportunity to purchase affordable group term life insurance on a payroll deduction basis. The important plan
More informationMetropolitan Life Insurance Company Statement of Health Form
Metropolitan Life Insurance Company Statement of Health Form Based on your enrollment, a Statement of Health is required to complete your request for group life insurance coverage. Below are instructions
More informationExtra Protection For Your Family
IDAHO Extra Protection For Your Family Group Decreasing Term Life Insurance The Voice for Public Pensions The Prudential Insurance Company of America 0182925-00001-00 The Voice for Public Pensions Dear
More informationU.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY #
U.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY # POLICY OWNER HOME PHONE INSURED HEIGHT WEIGHT DATE OF BIRTH SOCIAL SECURITY NO. WORK PHONE PLEASE NOTE ANY CHANGE OF
More informationGroup Term Life Insurance Application
Group Term Life Insurance Application Hartford Life and Accident Insurance Company Simsbury, Connecticut 06089 Policyholder American College of Emergency Physicians Policy No. AGL-1752 Certificate No.
More informationHelping to protect your income has never been easier.
Helping to protect your income has never been easier. Now with an online application process! Dear NAIFA Member, You provide insurance protection to others why not help protect yourself from serious financial
More informationGroup Term Life Insurance
Professional Pilot & Spouse Group Term Life Insurance No exclusions except suicide which is removed as an exclusion after two years of new coverage or increased coverage. Up to $150,000 in coverage available
More informationAdult Group Accident Medical Insurance
Adult Group Accident Medical Insurance Fraternals Church Groups Study Groups Amateur Music & Theatre Groups Gray Ladies Community Clubs Civic Clubs Etc. Benefits and Premium Rates Accidental Maximum Annual
More informationMetropolitan Life Insurance Company Statement of Health Form
Metropolitan Life Insurance Company Statement of Health Form Based on your enrollment, a Statement of Health is required to complete your request for group insurance coverage. Below are instructions for
More informationADA-Sponsored Disability Income Protection Plan Application for Insurance
Members Insurance Plans ADA-Sponsored Disability Income Protection Plan Application for Insurance IPWS15 Read all forms Complete sections 1 thru 9 Mail or Fax ALL completed forms Questions? 866.607.5334
More informationAMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502
P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 DISABILITY CLAIM FORM INSTRUCTIONS Enclosed is a claim form required in order to process disability payments on your loan. It is important that all questions
More informationAPPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company)
APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Member information (Please print or type) Name APTA
More informationSupplemental Life Insurance Benefit Program
Supplemental Life Insurance Benefit Program o Ordinary Life (Whole Life Insurance) Paid-Up At 65 o Ordinary Life (Whole Life Insurance) Paid for Life o Term Life Insurance Paid-Up At 65 o Term Life Insurance
More informationGroup/Association - Total and Permanent Disability / Waiver of Premium
Group/Association - Total and Permanent Disability / Waiver of Premium Connecticut General Life Insurance Company Life Insurance Company of rth America CIGNA Life Insurance Company of New York FRAUD WARNING:
More informationGROUP TERM LIFE INSURANCE APPLICATION PACKAGE
GROUP TERM LIFE INSURANCE APPLICATION PACKAGE How to Apply: 1. Complete the entire application form and return to administrator: * If you wish to request automatic withdrawal of premium payments from your
More informationINTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE
INTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE FOR U.S. Dollar Term Life Insurance for use when there is an international insurable interest involved. USES Employees of Foreign National Firms International
More informationUnderwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) APPLICATION for Group Term Life Insurance
Gynecologists Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) APPLICATION for Group Term Life Insurance The American College of Obstetricians
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 informationVOLUNTARY GROUP TERM LIFE INSURANCE: GUARANTEED ISSUE:
VOLUNTARY GROUP TERM LIFE INSURANCE: This plan offers you and your dependents an excellent opportunity to purchase affordable group term life insurance on a payroll deduction basis. The important plan
More informationLong Term Disability Insurance Conversion Plan
Long Term Disability Insurance Conversion Plan The Prudential Insurance Company of America INST-A002112-A Long Term Disability Insurance Conversion Plan If you have any questions regarding the conversion
More informationHow To Get A Health Insurance Plan For Free
NCE Premier Accident Insurance Program Underwritten by Unified Life Insurance Company GROUP ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Benefit Reduction at age 70 and 75 Unified Life Insurance Company
More informationDISABILITY CLAIM FORM
ACE American Insurance Company PROOF OF LOSS Mail to: ACE American Insurance Company Name of Group: UNIVERSITY OF CALIFORNIA P.O. Box 15417 Wilmington, DE 19850 800-336-0627 or 302-476-6194 Policy Number:
More informationNADA Dealer Life Insurance Program and Accidental Death & Dismemberment Simplified Issue Insurance Request Form
Request for Group Insurance From New York Life Insurance Company 51 Madison Avenue New York, NY 10010 MEMBER S FULL NAME ADDRESS NADA Dealer Life Insurance Program and Accidental Death & Dismemberment
More information1. Complete Application Form. 2. Complete Payment Method. 3. Fax or Mail Forms To: Application Instructions
Application Instructions The Florida Bar Member Group Term Life Insurance Plan 1. Complete Application Form Make sure to complete the form in its entirety. Incomplete applications will not be accepted.
More informationExtra Protection For Your Family
ILLINOIS Extra Protection For Your Family Group Decreasing Term Life Insurance National Conference on Public Employee Retirement Systems The Prudential Insurance Company of America 0204989-00002-00 Ed.
More informationAssurance Company. Eligibility. Spouse/Partner Term Life Insurance. Child Term Life Insurance. Accelerated Death Benefits
Assurance Company Group Term Life and Short Term Disability Insurance Eligibility You If you are an active member and work at least 80 hours per month, you are eligible to apply for Supplemental Term Life.
More informationCOMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS
COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS If you are filing for the medical expense benefit only under your accident policy, a claim form may not be needed
More informationProvisions Applicable to Group Term Life, AD&D, and Voluntary AD&D SECTION SIX AT-A-GLANCE
Provisions Applicable to Group Term Life, AD&D, and Voluntary AD&D SECTION SIX AT-A-GLANCE AD&D and Voluntary AD&D Limitations and Exclusions...pg. 50 Beneficiary Designations...pg. 52 Changes in Insurance...pg.
More informationApplication for Accidental Death Insurance
The Independent Order of Foresters ( Foresters ) - A Fraternal Benefit Society. U.S. Mailing Address: P.O. Box 179, Buffalo, NY 14201-0179 T. 800 828 1540 foresters.com Application for Accidental Death
More informationLife & Short Term Disability Group Insurance Plans
Life & Short Term Disability Group Insurance Plans for the Trustees of the Pennsylvania Municipal Authorities Association Insurance Fund GROUP INSURANCE PLANS Dear Authority Member: In response to your
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 informationIncome Protection Plan An Accident-Only Disability Income Insurance Plan. Income Protection Plus Plan
Income Protection Plan An Accident-Only Disability Income Insurance Plan Income Protection Plus Plan An Accident & Illness Disability Income Insurance Plan M IP_P B 110_110 HealthMarkets is the brand name
More information1 MEMBER INFORMATION Policy No. MZ0909533H0000A
Group Term Life Insurance Application Underwritten by Monumental Life Insurance Company, Cedar Rapids, IA Please complete the entire application. Print clearly in dark ink and mail to: Group Term Life
More informationTo file a claim: If you have any questions or need additional assistance, please contact our Claim office at 1-800-811-2696.
The Accident Expense Plus policy is a financial tool that helps cover high deductibles, co-pays and other expenses not covered by your primary major medical plan. This supplemental plan reimburses you
More informationName: DOB: / / SSN: Address: Street City State Zip Code
Accident Claim Form 100 North Parkway, Suite 200, Worcester, MA 01605 Phone: 877-201-9373 Fax: 508-853-2867 www.trustmarksolutions.com IMPORTANT NOTICE In order for us to consider any benefits, you must
More informationLife. Group Term Life Plans Group Sizes 2 or more. Underwritten by BEST Life and Health Insurance Co. LIFE-081809
Group Term Plans Group Sizes 2 or more Underwritten by BEST and Health Insurance Co. LIFE-081809 Insurance for Protection Group Term insurance provides valuable and affordable group benefits, providing
More informationGroup Life Insurance Amounts. Basic $ Voluntary $ Group Life Insurance Amounts. Spouse Effective Date: Child(ren) Effective Date:
DIRECTIONS: CONVERSION KIT GROUP LIFE INSURANCE (MONTANA) 1. Complete a separate Conversion Kit for each applicant. 2. Complete all sections below and the attached conversion application. 3. Mail the completed
More informationAMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502
P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 CREDIT LIFE CLAIM FORM INSTRUCTIONS Enclosed is a form required to process a claim for credit life benefits. It is important that all questions be fully
More informationUSLIFE Group Voluntary Term Life Insurance Coversheet
USLIFE Group Voluntary Term Life Insurance Coversheet Applicant Name: (If applicable see next section below) NYSBG Company Name: NYSBG Dues Level: Corporate $60 Current Check attached Corporate Employee
More informationGroup Whole Life 1-877-VIP-CSEA. Valuable Insurance Programs. Administered by. Sponsored by
Group Whole Life 1-877-VIP-CSEA Valuable Insurance Programs Sponsored by Administered by Important Benefits for CSEA members The Civil Service Employees Association (CSEA) is committed to providing its
More informationAPPLICATION FOR TERM CONVERSION (with Riders or Extra Benefits) OR POLICY REISSUE
72954101 APPLICATION FOR TERM CONVERSION (with Riders or Extra Benefits) OR POLICY REISSUE Liberty National Life Insurance Company P.O. Box 2612 Birmingham, AL 35202 A Nebraska Stock Company PART 1 Section
More informationHarvey Watt & Co. Aviation Health Association Group Term Life Insurance
Harvey Watt & Co. Aviation Health Association Group Term Life Insurance Underwritten by: ReliaStar Life Insurance Company A Member of the ING Family of Companies An Economic Program of Group Term Life
More informationMarketedBy: ContactUsat: A FAXOREMAILCOMPLETEDFORTO:770.643-4870, memberservices@wisebenefits.com,questions?cal1-800-825-7605 MarketedBy: FAXOREMAILCOMPLETEDFORTO:770.643-4870, memberservices@wisebenefits.com,questions?cal1-800-825-7605
More informationThe forms must be completed by a qualified person and signed with their occupational title as per its respective form.
Your ability to work and generate income is your greatest asset. If a disability ever left you unable to work, a combination of increased expenses and loss of income could create financial difficulties.
More informationHospital Indemnity Insurance Plan
Hospital Indemnity Insurance Plan Think about what would happen if you were hospitalized and unable to earn income. Your health insurance would cover your stay, but would you be able to cover your out-of-pocket
More informationGROUP TERM LIFE INSURANCE APPLICATION FOR MEMBERS OF THE PENNSYLVANIA BAR ASSOCIATION
GROUP TERM LIFE INSURANCE APPLICATION FOR MEMBERS OF THE PENNSYLVANIA BAR ASSOCIATION TO APPLY: Complete this form and return to USI AFFINITY 333 Technology Drive, Suite 255 Canonsburg, PA 15317 800-327-1550
More informationState of Louisiana All Employees
State of Louisiana All Employees Basic Term Life Insurance Basic plus Supplemental Term Life Insurance Accidental Death and Dismemberment Insurance Dependent Term Life Insurance The Prudential Insurance
More informationGROUP 10-YEAR LEVEL TERM LIFE INSURANCE APPLICATION FOR MEMBERS OF THE PENNSYLVANIA BAR ASSOCIATION
GROUP 10-YEAR LEVEL TERM LIFE INSURANCE APPLICATION FOR MEMBERS OF THE PENNSYLVANIA BAR ASSOCIATION TO APPLY: Complete this form and return to: USI AFFINITY 333 Technology Drive, Suite 255 Canonsburg,
More informationGroup Term Life Insurance Plan
STATE BAR OF WISCONSIN Group Term Life Insurance Plan Affordable group term life insurance, approved by the State Bar of Wisconsin as a benefit of your membership. 0232921 STATE BAR OF WISCONSIN Group
More information