Secure Ste Life Insurance Alication Secure Ste Life Insurance Do you have enough life insurance? If not, you re not alone. Studies show that 93% of Americans say they need it, too. Grange makes it easy to cover all of your insurance needs, including life insurance. Secure Ste Life Insurance gives you eace of mind and rovides lifetime financial rotection for your loved ones. With this simle alication, it s easy to take the next ste in securing your family s future. With just 2 medical questions, your olicy can be aroved today!
Take the next ste in securing your family s future... A Secure Ste Life Insurance olicy is a ermanent life insurance lan that rovides eace of mind with lifetime financial rotection. You can rest easy knowing that your ayments never change and the cash value in your olicy is guaranteed regardless of what haens in the market. When you own a Secure Ste Life Insurance olicy: Most imortantly, your loved ones are financially rotected Your remiums/ayments never change Your cash value is guaranteed You own a ermanent olicy that never needs to be renewed or converted You may be able to save more on your Grange auto olicy with a qualifying Life olicy After you comlete the alication and rovide the modal remium or Easy Pay Authorization, your coverage* is effective immediately. You should exect to receive your olicy in the mail in about 2 weeks. Here s what you urchased: Policy Year Secified Amount 1 & 2 400% of the total annualized remium based on monthly mode; accidental death ays secified amount minus the death benefit. 3 + $ Here s what you ll ay: Payment mode: Payment amount: $ Congratulations on taking the Secure Ste for your family s future! *Coverage is subject to the terms of your olicy contract and the Binding Receit below. During the first two olicy years, this olicy will ay a death benefit equal to 400% of the total annualized remium based on monthly mode. The olicy will ay the secified amount minus the death benefit during the first two years of the olicy contract if death is as a result of an accident. After that, the death benefit will be the secified amount. Life Insurance Binding Receit Grange Life Insurance Comany 671 South High Street, P.O. Box 1218 Columbus, Ohio 43216-1218 (800) 399-3797 Received from Date the sum of $ being the ayment of one modal remium, or if monthly, authorization to draft my first monthly remium using Easy Pay ayment lan. The insurance requested will start on the date of this alication only if: (a) the first remium is aid (check or draft must be honored uon resentation or insurance is void); (b) questions 1, 2, and 4 are answered No ; (c) the roosed insured is a citizen or ermanent resident of the United States; and (d) the health of the roosed insured is as described in the alication of coverage. Should the alication be declined, or not aroved as alied for within sixty days from the date of this Receit, this Receit shall be void, and any amount aid will be refunded. Agent s Signature Agent s Phone Number Make check ayable to Grange Life Insurance Comany. Do not make check ayable to the agent, agency or leave ayee line blank.
Grange Life Insurance Comany 671 South High Street, P.O. Box 1218 Columbus, Ohio 43216-1218 (800) 399-3797 Notice Concerning Policyholder Rights in an Insolvency Under the Minnesota Life and Health Insurance Guaranty Association Law If the insurer that issued your life, annuity, or health insurance olicy becomes imaired or insolvent, you are entitled to comensation for your olicy from the assets of that insurer. The amount you recover will deend on the financial condition of the insurer. In addition, residents of Minnesota who urchase life insurance, annuities, or health insurance from insurance comanies authorized to do business in Minnesota are rotected, SUBJECT TO LIMITS AND EXCLUSIONS, in the event the insurer becomes financially imaired or insolvent. This rotection is rovided by the Minnesota Life and Health Insurance Guaranty Association. Minnesota Life and Health Insurance Guaranty Association 4760 White Bear Parkway, Suite 101, White Bear Lake, MN 55110 The maximum amount the guaranty association will ay for all olicies issued on one life by the same insurer is limited to $500,000. Subject to this $500,000 limit, the guaranty association will ay u to $500,000 in life insurance death benefits, $130,000 in net cash surrender and net cash withdrawal values for life insurance, $500,000 in health insurance benefits, including any net cash surrender and net cash withdrawal values, $250,000 in annuity net cash surrender and net cash withdrawal values, $410,000 in resent value of annuity benefits for annuities which are art of a structured settlement or for annuities in regard to which eriodic annuity benefits, for a eriod of not less than the annuitant s lifetime or for a eriod certain of not less than ten years, have begun to be aid on or before the date of imairment or insolvency, or if no coverage limit has been secified for a covered olicy or benefit, the coverage limit shall be $500,000 in resent value. Unallocated annuity contracts issued to retirement lans, other than defined benefit lans, established under section 401, 403(b), or 457 of the Internal Revenue Code of 1986, as amended through December 31, 1992, are covered u to $250,000 in net cash surrender and net cash withdrawal values, for Minnesota residents covered by the lan rovided, however, that the association shall not be resonsible for more than $10,000,000 in claims from all Minnesota residents covered by the lan. If total claims exceed $10,000,000, the $10.000,000 shall be rorated among all claimants. These are the maximum claim amounts. Coverage by the guaranty association is also subject to other substantial limitations and exclusions and requires continued residency in Minnesota. If your claim exceeds the guaranty association s limits, you may still recover a art or all of that amount from the roceeds of the liquidation of the insolvent insurer, if any exist. Funds to ay claims may not be immediately available. The guaranty association assesses insurers licensed to sell life and health insurance in Minnesota after the insolvency occurs. Claims are aid from this assessment. THE COVERAGE PROVIDED BY THE GUARANTY ASSOCIATION IS NOT A SUBSTITUTE FOR USING CARE IN SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND FINANCIALLY STABLE. IN SELECTING AN INSURANCE COMPANY OR POLICY, YOU SHOULD NOT RELY ON COVERAGE BY THE GUARANTY ASSOCIATION. THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDERS OF LIFE, ANNUITY, OR HEALTH INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR INSURANCE CARRIER BECOMES FINANCIALLY INSOLVENT. THIS NOTICE IN NO WAY IMPLIES THAT THE COMPANY CURRENTLY HAS ANY TYPE OF FINANCIAL PROBLEMS. ALL LIFE, ANNUITY, AND HEALTH INSURANCE POLICIES ARE REQUIRED TO PROVIDE THIS NOTICE. L-15-32 (1/2010) MN
Alication for: Graded Benefit Whole Life Grange Life Insurance Comany 671 South High Street, P.O. Box 1218 Columbus, Ohio 43216-1218 (800) 399-3797 PROPOSED INSURED Name Male Female Address DOB Age City State Zi Tax ID/SSN Phone ( ) Email Are you a citizen of the United States? If No, lease rovide a coy of your Permanent Resident Card. BENEFICIARY INFORMATION (erson to be aid at death) Beneficiary Name % Primary Contingent BENEFIT AMOUNT $50,000 $35,000 $25,000 $15,000 Other $ PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS (PROPOSED INSURED) Yes No MEDICAL/HEALTH QUESTIONS 1. Have you been declined for Life Insurance in the ast 12 months? Yes No 2. Are you currently receiving hosice care; waiting on an organ or tissue translant; or ever been diagnosed with a terminal illness; or tested ositive for the HIV (Human Immunodeficiency Virus), or been diagnosed by a member of the medical rofession as having ARC (AIDS Related Comlex), or AIDS (Acquired Immune Deficiency Syndrome)? Yes No For Wisconsin Alicants Only: Test results of AIDS/HIV received at anonymous counseling and testing sites or results received from a home test kit need not be disclosed. STOP: If question 1 or 2 is answered Yes, the roduct is not available. TOBACCO USE 3. Have you smoked one or more cigarettes in the ast 12 months? Yes No INSURANCE INFORMATION 4. Will any Life Insurance or Annuities for this or any other comany be relaced, discontinued, reduced or changed if insurance now alied for is issued? Yes No 5. Do you currently have any other Life Insurance or Annuities in force? Yes No STOP: If question 4 is answered Yes, the roduct is not available. PAYMENT INFORMATION Relationshi to Insured DOB SSN I wish to be billed : (check one) Monthly through Easy Pay (Please comlete Easy Pay Authorization) Annually Other If monthly, I authorize Grange Life to draft my first monthly remium. If mode other than Easy Pay is selected, I am enclosing the first modal remium of $. EASY PAY AUTHORIZATION Monthly Amount: $ Routing Number: Account Number: Financial Institution: PLEASE ATTACH A COPY OF A VOIDED CHECK By roviding my Financial Institution name and account information, I hereby authorize Grange Life to initiate debit entries to my checking/savings account indicated above and the Financial Institution to debit the same such account. Grange Life will draft the first ayment when the alication is received in the Home Office. Subsequent monthly drafts will occur on the same day each month as the effective date unless otherwise requested. Secial Draft Date Request: Secial Instructions Section (If more sace is needed, an additional blank sheet may be attached.) OVER PLEASE
AUTHORIZATION I reresent that the statements and answers recorded on this alication are true and comlete and agree that they will form a art of any insurance olicy issued hereon. I also understand that the information on this alication will be relied uon to determine insurability and that incorrect information may result in coverage being voided, subject to the Incontestability Provision. TEMPORARY INSURANCE I agree that the insurance requested above will start uon the date of this alication only if: (a) the first remium is aid; (b) questions 1, 2 and 4 are answered No ; (c) the roosed insured is a citizen or ermanent resident of the United States; and (d) the health of the roosed insured is as described above. Otherwise, the insurance will not take effect until a olicy is issued by Grange Life and the first remium is aid. The initial remium will rovide coverage from the olicy issue date until the date the next remium is due. Should the alication be declined, the amount aid will be refunded. No agent can accet risks or make or change contracts or waive Grange Life s rights or requirements. All statements made are reresentations, not warranties. The entire contract will consist of the olicy and this alication. If the alicant is other than the roosed insured, the alicant will be the owner of this olicy. The owner has the right to cancel this alication at any time by contacting their agent or Grange Life in writing. FRAUD NOTICE WE ARE REQUIRED BY LAW TO GIVE YOU THE FOLLOWING NOTICE: Ohio - Any erson who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an alication or files a claim containing a false or decetive statement is guilty of insurance fraud. Kentucky - Any erson who knowingly and with intent to defraud any insurance comany or other erson files an alication for insurance containing any materially false information or conceals, for the urose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. IN ALL OTHER STATES, THE FOLLOWING NOTICE APPLIES: Any erson who knowingly and with intent to injure or defraud any insurer files an alication or claim containing any false, incomlete or misleading information may be subjected to criminal enalties and the denial of coverage for claims made under the olicy of insurance. SIGNATURE Full Name of Proosed Insured (rinted) Signature of Proosed Insured Signed at (City, State) on, 20 AGENT S REPORT I certify that the information sulied by the roosed insured has been fully and accurately recorded on the alication, and I have received the first full modal remium shown above or received all information for Easy Pay enrollment. To the best of your knowledge does the alicant have any existing life or annuity olicies? Will the insurance alied for relace any existing insurance? Yes No Yes No Agent s Name (rinted): Agency Name: Agent s Signature: Agent Number:
Auto Home Life Business grangeinsurance.com 671 South High Street P.O. Box 1218 Columbus, Ohio 43216-1218 (800) 399-3797