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 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
R-868-5, Ed. 10-06
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
❑ M
❑ F
Marital Status
❑ M
❑ 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. Height
ft. In. Weight lbs.
11.
12.
13.
14.
15.
16. Total Life Insurance in Force on each Proposed Insured Proposed
Insured No. Company Face Amount ADB Amount
PART 3 – THIS SECTION SHOULD BE COMPLETED IF
• 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)
• 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)
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
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 12 - 14 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 Insured No. Ques.
no. Explanation Date Hospital Duration Physician Address
R-868-5, Ed. 10-06
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.)
AgENT’S STATEMENT
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’S REMARkS
Agent Number / /
Branch agency Client no.
Telephone Numbers / E-Mail Information Yes No
Home: __________________________________________ During Day ❑ ❑
Business: __________________________________________ Extension _____________ During Day ❑ ❑
Cell Phone: __________________________________________ During Day ❑ ❑
E-Mail 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.
R-868-5, Ed. 10-06
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 866-692-6901 (TTY 866-346-3642). 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 02184-8734.
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 www.mib.com.
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 35202.