• No results found

application for survivorship joint life insurance Part 1

N/A
N/A
Protected

Academic year: 2021

Share "application for survivorship joint life insurance Part 1"

Copied!
6
0
0

Loading.... (view fulltext now)

Full text

(1)

application for survivorship joint life insurance

Part 1

AMERITAS LIFE INSURANCE CORP.

LINCOLN, NEBRASKA 68501 (ALIC)

1010

Street ___________________________________________________

City _______________________ State ______ Zip Code __________

INFORMATION REGARDING INSURED A INFORMATION REGARDING INSURED B

2.A. Mailing Address Bus.  Res. 

Street ___________________________________________________

City _______________________ State ______ Zip Code __________

2.B. Mailing Address Bus.  Res. 

Street ___________________________________________________

City _______________________ State ______ Zip Code __________

Mailing Address Bus.  Res. 

1.A. Name: Last First Middle

3.A. Occupation Date Employed

Employer’s Name

Primary Name: Last First Middle

Beneficiary:

Contingent Name: Last First Middle

Beneficiary:

3.B. Occupation Date Employed

Employer’s Name

4.A. Life Insurance in force, on Insured A. (Indicate if none) 4.B. Life Insurance in force, on Insured B. (Indicate if none)

5. POLICYOWNER INFORMATION

6. SUCCESSOR-OWNER INFORMATION

7. BENEFICIARY INFORMATION

8.A. TELEPHONE INTERVIEW INFORMATION (Insured A)

Telephone: Area Number CONVENIENT TO CALL Home ______ ______ ______________________  a.m.  p.m. day _______

Business ______ ______ ______________________ a.m.  p.m. day _______

Show any unusual name pronunciation phonetically __________________________

May we interview the spouse or an adult member of the family? _________________

8.B. TELEPHONE INTERVIEW INFORMATION (Insured B)

Telephone: Area Number CONVENIENT TO CALL Home ______ ______ ______________________ a.m.  p.m. day _______

Business ______ ______ ______________________ a.m.  p.m. day _______

Show any unusual name pronunciation phonetically __________________________

May we interview the spouse or an adult member of the family? _________________

ENDORSEMENTS AND CORRECTIONS. For completion at the Home Office. No change in the amount, age at issue, classification, plan of insurance or benefits shall be effective unless agreed to in writing by me. This space will not be used in MD, PA or WV or any other state if not allowed by statute or Insurance Department regulation.

Insured A’s Soc. Sec. No.

Birthdate

Face Amount

Owner of the policy is to be (choose one): Insured A Insured B Joint Owner-Insureds Other * (please explain and complete below)

*Other

____________________________________________________________

____________________________________________________________

Street ___________________________________________________

City _______________________ State ______ Zip Code __________

Mailing Address Bus.  Res. 

Upon death of either Owner-Insured (if joint owner-insureds) or death of owner, the Successor-Owner is designated as: (choose one)

Surviving Insured Decedent Owner’s Estate Other * (please complete below)

*Other

Term Riders Amt. Acc. Death Amt. Yr. Iss. Company Face Amount Term Riders Amt. Acc. Death Amt. Yr. Iss. Company

Birthplace (State) Age

Nearest Birthday

Birthdate Birthplace (State) Age

Nearest Birthday

Male

Female

1.B. Name: Last First Middle

Male

Female

Owner’s Soc. Sec./Tax I.D. No.

Soc. Sec./Tax I.D. No.

Relationship to Insureds _____________________________________

Insured B’s Soc. Sec. No.

Relationship to Insureds

Relationship to Insureds

(If a Trust give Trustee, Trust name and Trust date.)

Unless otherwise indicated, multiple beneficiaries shall be paid equally, to the survivor or survivors.

(2)

JL-8 Rev. 6-98 MO Page 2 of 4 Pages 112502L

9. STATEMENTS FROM THE PROPOSED INSUREDS

10. POLICY INFORMATION AND OPTIONAL BENEFITS

11. BENEFICIARY INFORMATION FOR FIRST TO DIE TERM RIDER ONLY Unless otherwise indicated, multiple beneficiaries shall be paid equally, to the survivor or survivors.

(Please explain any “yes” answers to these questions in the details section)

Insured A Insured B

Yes No Yes No

a. Will the insurance now being applied for replace any insurance or annuity in this or any other company?    

b. Has any company postponed or modified insurance?    

c. Is any other life insurance application now pending or contemplated with any other company?    

d. Have you been charged with a driving violation or had your license suspended or had a restriction placed on your license within

the past 5 years? (If yes, provide:) Driver’s license number ___________________ State of Issue ______________________     Driver’s license number ___________________ State of Issue ______________________

e. Have you participated in any vehicle racing, parachuting, hang gliding, scuba diving or rodeos within the past 2 years or is any

such activity contemplated?    

f. Have you flown within the past 3 years as a pilot, student pilot, crew member, or had any flying duties, or is any such activity

contemplated?    

g. Have you smoked one or more cigarettes in the past twelve months?    

h. Have you used any form of tobacco or nicotine substitute in the past twelve months?    

(If yes, please provide date of last use) ___________________________________

i. Do you anticipate travel in a foreign country in the near future? (If so, where? ____________________________________)     Details of “yes” answers. Identify question number and Insured “A” or “B”, where applicable:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

First Name: Last First Middle

Beneficiary:

Contingent Name: Last First Middle

Beneficiary:

Relationship to Insureds

Relationship to Insureds POLICY BENEFITS

Specified Amount $ ________________________________

Death Benefit Option (Select only one choice)

 Option A (death benefit is the specified amount)

 Option B (death benefit is the specified amount plus the accumulation value)

Optional Benefit Riders (Select only the riders you want included)

 First to Die Term Rider* with Rider Specified Amount $ _________________

*NOTE: Please provide Beneficiary Information below.

 Waiver of Deductions on Disability of

Covered Insured(s) (choose one or both):  Insured A  Insured B

 Waiver of Deductions on First Death (choose one or both):  Insured A  Insured B

 Policy Split Option Rider (please designate):

Insured A _____ % Insured B ______ %

 ___________________________________

 ___________________________________

(3)

1010

13. A. PERSONAL HISTORY OF INSURED A 13 .B. PERSONAL HISTORY OF INSURED B

b. Are you a citizen of the United States? Yes No (If no, explain)

c. Have you used a different name within the past 5 years? Yes No If “Yes”, give names:

c. Have you used a different name within the past 5 years? Yes No If “Yes”, give names:

b. Are you a citizen of the United States? Yes No (If no, explain)

a. Income from Occupation

$ ____________________

Estimated Net Worth

$ __________________

Other Income $ _____________

(dividends, rental income, interest, etc.)

Source ____________________

a. Income from Occupation

$ ____________________

Estimated Net Worth

$ __________________

Other Income $ _____________

(dividends, rental income, interest, etc.)

Source ____________________

12. A. HEALTH HISTORY (Answer the following questions regarding the Proposed Insured A.)

For the following questions “HIV” means Human Immunodeficiency Virus and “AIDS” means Acquired Immune Deficiency Syndrome.

Name of personal physician_____________________________________________________________________________________________________________________________

Addres _____________________________________________________________________________________________________________ Phone_________________________

Reason last consulted __________________________________________________________________________________________________ Date _________________________

What treatment was given or medication prescribed? _________________________________________________________________________________________________________

Has the Insured: (If yes, please explain)

a. Ever been treated by a physician or any person licensed in the medical profession (other than a nurse) and acting within the scope of the license in the last ten years for any of the following: Heart trouble, stroke, heart murmur, elevated blood pressure, lung or respiratory disorder, kidney disorder,

tumor, cancer, digestive disorder, diabetes, nervous or mental disorder?  Yes  No

b. Consulted a physician or been examined or treated at a hospital or other medical facility in the last five years?  Yes  No c. Ever used narcotics, barbiturates, amphetamines, cocaine, LSD, marijuana or hallucinogenic drugs?  Yes  No

d. Ever received counseling or treatment for the use of alcohol or drugs?  Yes  No

e. Have you ever been a member of any support group for the use of alcohol or drugs?  Yes  No f. Exact Height ________ ft. ________ in. Exact Weight ________ lbs. l Gained l Lost __________ pounds in past year.

g. Please explain any “Yes” answers.

(If none, so state)

12. B. HEALTH HISTORY (Answer the following questions regarding the Proposed Insured B.)

For the following questions “HIV” means Human Immunodeficiency Virus and “AIDS” means Acquired Immune Deficiency Syndrome.

Name of personal physician_____________________________________________________________________________________________________________________________

Addres _____________________________________________________________________________________________________________ Phone_________________________

Reason last consulted __________________________________________________________________________________________________ Date _________________________

What treatment was given or medication prescribed? _________________________________________________________________________________________________________

Has the Insured: (If yes, please explain)

a. Ever been treated by a physician or any person licensed in the medical profession (other than a nurse) and acting within the scope of the license in the last ten years for any of the following: Heart trouble, stroke, heart murmur, elevated blood pressure, lung or respiratory disorder, kidney disorder,

tumor, cancer, digestive disorder, diabetes, nervous or mental disorder?  Yes  No

b. Consulted a physician or been examined or treated at a hospital or other medical facility in the last five years?  Yes  No c. Ever used narcotics, barbiturates, amphetamines, cocaine, LSD, marijuana or hallucinogenic drugs?  Yes  No

d. Ever received counseling or treatment for the use of alcohol or drugs?  Yes  No

e. Have you ever been a member of any support group for the use of alcohol or drugs?  Yes  No

f. Exact Height ________ ft. ________ in. Exact Weight ________ lbs. l Gained l Lost __________ pounds in past year.

g. Please explain any “Yes” answers.

(If none, so state)

(4)

JL-8 Rev. 6-98 MO Page 4 of 4 Pages 112502L

Agency Representative Representative

Code REPRESENTATIONS AND AGREEMENTS

I represent to the best of my knowledge and belief that all statements and answers to this application, Parts 1 and 2 are complete and true. I agree as follows:

1. Any policy issued as a result of this application will, with this application, and any supplemental applications, be the entire insurance contract.

2. No agent, broker or medical examiner can: a) waive the answers to any questions in this application; b) make or change any insurance contract; or c) waive any rights or rules of the Company.

3. This insurance will be effective when ALL of the following are met:

a. The policy issued by the Company is delivered to and accepted by the applicant;

b. The first full premium is paid.

4. The Company may change this application by an appropriate notation in the space marked “Endorsements and Corrections”: a) to correct apparent errors or omissions; and b) to conform it with any policy rider that may be issued. No change will be made in the following without the applicant’s written consent: a) amount of insurance; b) plan of insurance; c) age at issue; d) classification of risk; e) benefits. Acceptance of the policy ratifies: a) any amendments; b) the beneficiary designation; c) payment of proceeds; and d) ownership of policy.

AUTHORIZATION

I authorize any licensed physician, medical practitioner, hospital, clinic or other medically related facility, insurance company, agency conducting investigative consumer reports or any information service or financial institution, family member, or associate to release to ALIC or any person or entity acting on its behalf, any personal information which is on file and relates to my health or mental condition, general character, driving records, use of alcohol and drugs, and hobbies of a hazardous nature. I understand that any information obtained will be used to determine my eligibility for insurance and/or for any benefits in the event of a claim.

In addition, I authorize MIB, Inc. (Medical Information Bureau) to release to Ameritas Life Insurance Corp., or its reinsurers, any personal information which is on file and relates to me.

This authorization, or a photocopy of it shall remain valid for use by Ameritas Life Insurance Corp. for two (2) years from the date below.

I also agree that I have received and read the “Notice of Ameritas Life Insurance Corp.’s Insurance Information Practices”, the MIB, Inc. (Medical Information Bureau) and Investigative Consumer Reports. I also understand that my authorized representative and I can receive a copy of this authorization if we so desire.

CERTIFICATION OF SOCIAL SECURITY (TIN) NUMBER

For joint ownership, the first person’s name and Soc. Sec. No. (TIN), i.e., Owner-Insured A will be listed as the TIN of record. This person is certifying as follows:

I certify under penalty of law that: 1) the number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2) I am not subject to backup withholding because: a) I am exempt from backup withholding, or b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or c) the IRS has notified me that I am no longer subject to backup withholding.

You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Dated at

The following questions are directed to the agent if involved in solicitation:

Do you have any knowledge or reason to believe that replacement of existing insurance or annuity coverage may be involved? (If “yes” give details) . . .  Yes  No Does the Owner (Applicant) have any existing policies of life or annuity? . . .  Yes  No Did you see each Proposed Insured at the time of application completion? . . .  Yes  No You must positively identify the Owner with a government-issued picture form of identification (I.D.). Examples of acceptable forms are: Driver’s License, Passport, Military I.D., Green Card.

You must also obtain a copy of the government-issued I.D. and submit it with this application. If it is not possible to obtain a copy, you must provide the following information:

What was or will be the source of funds used to apply for the policy?

 Checking Account?  Savings Account?  Proceeds from Investments?  Inheritance?  Other ____________________________________________________

X

Signature and Title of Firm Officer

X

Signature of Ameritas Representative/Agent (where required)

Expiration Date I.D. #

What form of I.D. did you use?

X

Signature of Insured B

X

Signature of Owner if not an Insured (If a Corporation or other Firm, show full name of Firm)

X

Signature of Insured A Date

City and State

(5)

The following information should be reviewed in

conjunction with completion of an Ameritas Life

Insurance Corp. application for insurance. Please

detach and retain in your records.

NOTICE OF AMERITAS LIFE INSURANCE CORP.’S INSURANCE INFORMATION PRACTICES To issue an insurance policy, we need to obtain information about you and any other persons proposed for insurance.

Some of that information will come from you and some will come from other sources. That information and any subsequent information collected by us may in certain circumstances be disclosed to third parties without your specific authorization.

All proposed insured persons (or their Parent or Guardian, if juvenile) have a right of access and correction with respect to the information collected about himself or herself except information which relates to a claim, or civil or criminal proceeding.

If you wish to have a more detailed explanation of our information practices, please contact: Ameritas Life Insurance Corp., P.O. Box 81889, Lincoln, NE 68501-1889.

In an effort to provide better service and products to you, Ameritas Life Insurance Corp. may use information given by you to develop marketing data. Your name will not be associated with this data in any way. If you do not want us to use information obtained from you for these purposes, please contact us within ten (10) days. We need to know within 10 days since once the information is separated from your application, we will be unable to personally identify the information with you or your application. The address at which to contact us is: Ameritas Life Insurance Corp., P.O. Box 81889, Lincoln, NE 68501-1889.

Two of our sources of information about you are MIB, Inc.

(Medical Information Bureau) and Investigative Consumer Reports. The following paragraphs describe these sources.

MIB, INC. (MEDICAL INFORMATION BUREAU) Information regarding the Proposed Insured's insurability will be treated as confidential. We or our reinsurers may, however, make a brief report thereon to MIB, Inc., a non- profit membership organization of life insurance companies which operates an information exchange on behalf of its members. If any of the Proposed Insureds apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such company with the information it may have in its file.

Upon receipt of a request from any Proposed Insured (or the Parent or Guardian, if juvenile), the Bureau will arrange disclosure of any information it may have in the Proposed Insured's file. If there is a question as to the accuracy of information in the Bureau's file, the Bureau may be contacted to seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the Bureau's information office is P.O.

Box 105, Essex Station, Boston, MA 02112, telephone number (617) 426-3660.

We or our reinsurers may also release information in our file to other life insurance companies to whom the Proposed Insured may apply for life or health insurance or to whom a claim for benefits may be submitted.

(6)

JL-8 Rev. 6-98 MO 112502L INVESTIGATIVE CONSUMER REPORTS

Depending on the size of policy applied for, we may request that an investigative consumer report about the Proposed Insured be given to us. It will be conducted by a national organization skilled in obtaining information about people.

The kind of information we may be seeking includes such facts as residence verification, marital status, occupation, general reputation, personal characteristics and mode of living. It will be obtained through personal interviews with the Proposed Insured's friends, neighbors, associates and other acquaintances. Inquiries will not be directed toward determining the Proposed Insured's sexual orientation. Also, no adverse underwriting decision will be made because a report shows that a Proposed Insured has demonstrated AIDS-related concerns or has sought AIDS-related counseling.

The Proposed Insured, upon written request will be informed whether or not an investigative report was requested, and if a report was ordered, the name and address of the Consumer reporting agency. A copy of this report is available to the Proposed Insured upon request. He or she may call us at the following number and ask for the Underwriting Department:

1-800-745-6665.

ADVERSE UNDERWRITING DECISION

After review of the application submitted on the Proposed Insured(s), if the policy cannot be issued as applied for, we will provide the specific reasons for this decision upon written request from the applicant. Send your written request to the Underwriting Department at Ameritas Life Insurance Corp., P.O. Box 81889, Lincoln, NE 68501-1889.

MEDICAL AUTHORIZATION

The medical authorization on the application or a photocopy of it, shall remain valid for use by ALIC for the duration of any claim for benefits.

References

Related documents

14. Do you have any other medical insurance at this time? 15. I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medically related

I authorize and direct any medical practitioner, hospital or clinic, or medically related facility, insurance company, law enforcement agency or other organization, institution

I certify that the above is true and complete and I hereby authorize any physician, medical practitioner, hospital, clinic or other medically related facility, insurance company,

I hereby authorize any licensed physician, medical practitioner, hospital, clinic or medical or medically related facility, insurance company, MIB Inc., (“MIB”) or other

I hereby authorize any: physician, medical practitioner, hospital, clinic or other medical related facility, insurance company, insurance support organization, business

I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, the Medical Information Bureau,

I authorize any physician, medical practitioner, hospital, clinic, other medical or medically-related facility, insurance company or other organization, institution or person that

I, by signing below, hereby authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medically-related facility, insurance company, the group