PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LIMITED Pacific Guardian Tower •1440 Kapiolani Boulevard, Suite 1700
Honolulu, Hawaii 96814-3698 • (808) 955-2236
JUVENILE SHORT FORM APPLICATION (Coverage up to $100,000 and ages 15 days old through 14 years of age.)
PROPOSED INSURED’S INFORMATION
Full Legal Name (Last, First, Middle) Sex Date of Birth
Birth
State Height / Weight Soc. Sec. No.
AMOUNT OF INSURANCE:
Street Address No. of Years
City State Zip Code Telephone No.
(Check one) ■■ $50,000 ■■ $75,000 ■■ $100,000 ■■ $
Mode of Payment: ■■■■ Annual ■■■■ Semi-Annual ■■■■ Quarterly ■
■ ■
■ Automatic Bank Draft--Starting day of each month (not available on the 29th, 30th and 31st) Automatic Premium Loan (APL) is active unless checked ■■■■ NO
STATEMENT OF HEALTH
Give complete dates and details to any “Yes” answers in the Detail Section. State the name and address of the doctor, hospital or clinic. Use a separate page if necessary.
1. Within the past five years, has the proposed insured child ever had or been advised he/she:
a) Had any congenital disease or disorder, any disorder, of the heart, lungs, nervous system, digestive system, urinary system any disorder of the blood, kidney, liver, brain, bone or joints, or any mental disorder?
b) Had been treated for, or told by a member of the medical profession to have had AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS Related Complex), or any other immunological disorder?
c) Had been declined, rated, or postponed for life insurance?
d) Used controlled substances or drugs not prescribed by a physician? e) Received treatment of counseling due to alcohol or drug use?
2. Does the Proposed Insured currently have an existing life insurance or annuity contract? If “Yes”, please complete Appendix A.
Yes No
DETAIL SECTION:
Form No. UW-190 Rev. 1-06 1
Owner
BENEFICIARY: Name of Primary Beneficiary: Relationship:
Name of Contingent Beneficiary: Relationship:
OWNERSHIP INFORMATION Full Legal Name (Last, First, Middle)
Address (Street, City, State, Zip) Sex
Relationship to Proposed Insured Birth State Date of
Birth Soc. Sec. No. Telephone No.
Contingent Owner ■
■ ■
■ Horizon Junior (2007) ■■■■ Horizon Junior+ (2007) (No. of years to pay, 10-30): Yrs.
POLICY NUMBER
Form No. UW-190 Rev. 1-06 2
A) CONDITIONAL RECEIPT ACKNOWLEDGEMENT ■■■■ (Check if applicable)
By signing below, I (we) have paid $___________________ to the agent or broker in exchange for a Conditional Receipt and agree to conditions therein.
I (We) acknowledge the possession of the Receipt and certify that I (we) have read it and the agreement in the application. I (We) further acknowledge that the terms, conditions and maximum amount of insurance under the Receipt and the agreement in the application have been explained to me (us) fully by the agent and that I (we) understand them and agree to them.
B) AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
C) DECLARATION
I (We) agree that this application (and any questionnaires required) shall form a part of any policy issued, that the Company specifically disclaims any agent’s authority to waive a complete answer to any question in the application, pass on insurability, make or alter any contract or waive any of the Company’s other rights or requirements,
that no insurance shall take effect unless and until the policy has been delivered to and received and accepted by me (us) and the full first premium paid during the lifetime and good health of the Proposed Insured (except as provided in the Conditional Receipt if a premium has been paid and acknowledged above and such Receipt issued). By signing below, I (we) acknowledge that I (we) have read the above questions and answers and hereby declare that they are complete and true to the best of my (our) knowledge and belief.
Under penalties of perjury I (we), as owner(s), hereby certify (1) that the Social Security or Taxpayer I.D. number(s) above on this application is/are correct and (2) that I (we) am/are currently not subject to backup withholding. (Cross out (2) if not correct.) The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
DECLARATION, AUTHORIZATION AND AGREEMENTS
Dated at this day of ,
X
Name or Signature of Proposed Insured Child Signature of Parent of Legal Guardian for Proposed Insureds age 18 and under
Signature of Witness/ Agent Signature of Owner, if Other than Parent or Legal Guardian
Print Agent’s Name Agent’s No.
City State month year
the purpose of evaluating my (our) application for insurance.
I (We) agree that this authorization shall be valid for a period of two years and six months from the date signed. I (We) further agree that a photocopy of this authorization shall be as valid as the original. I (We) acknowledge that I (we) have received and read a copy of this authorization.
I (We) have also received copies of notices regarding “Investigative Consumer Reports,” “Medical Information Bureau, Inc.” and “Notice of Insurance Information Practices.”
Form No. UW-206 Rev. 7/04 THIS COPY TO HOME OFFICE
Authorization for Release of
Health-Related Information To Pacific Guardian Life Insurance Company, Limited
(This authorization complies with the HIPAA Privacy Rule)
Name of proposed insured/patient (please print) Date of birth
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf within the past 10 years (“My Providers”) to disclose my entire medical record and any other protected health information concerning me to the Pacific Guardian Life Insurance Company, Limited (the “Company”) and its agents, employees and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental ilness and the use of alcohol, drugs, and tobacco, but excludes psychoterapy notes.
This authorization also authorizes the Medical Information Bureau, Inc., any consumer reporting agency, or other insurance support organization or employer having information or records relative to age, character, habits, avocations, finances, occupation, general reputation, credit, other insurance coverage, participation in hazardous activities, of me (us) or my (our) minor children on whom insurance is applied for, to furnish any and all such information to the Company or its reinsurers, agents, and any insurance support organization acting on its behalf for the purpose of evaluating my application for insurance.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and disclose my entire medical record without restriction.
This protected health information is to be disclosed under this Authorization so that the Company may: 1) underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtain
reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with the Company.
This authorization shall remain in force for 30 months following the date of my signature below, and a copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to the Company at 1440 Kapiolani Boulevard, Suite 1700; Honolulu, HI 96814, Attention: Privacy Official. I understand that a revocation is not effective to the extent that any of My Providers has relied on this Authorization or to the extent that the Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to the authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information.
I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, the Company may not be able to process my application, or if coverage has been issued may not be able to make any benefit payments. I acknowledge that I have received a copy of this authorization.
Signature of Proposed Insured/Patient (or Personal Representative) Date
Description of Personal Representative’s Authority or Relationship to Patient Date
Form No. UW-206 Rev. 7/04 THIS COPY TO PROPOSED INSURED
Authorization for Release of
Health-Related Information To Pacific Guardian Life Insurance Company, Limited
(This authorization complies with the HIPAA Privacy Rule)
Name of proposed insured/patient (please print) Date of birth
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf within the past 10 years (“My Providers”) to disclose my entire medical record and any other protected health information concerning me to the Pacific Guardian Life Insurance Company, Limited (the “Company”) and its agents, employees and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental ilness and the use of alcohol, drugs, and tobacco, but excludes psychoterapy notes.
This authorization also authorizes the Medical Information Bureau, Inc., any consumer reporting agency, or other insurance support organization or employer having information or records relative to age, character, habits, avocations, finances, occupation, general reputation, credit, other insurance coverage, participation in hazardous activities, of me (us) or my (our) minor children on whom insurance is applied for, to furnish any and all such information to the Company or its reinsurers, agents, and any insurance support organization acting on its behalf for the purpose of evaluating my application for insurance.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and disclose my entire medical record without restriction.
This protected health information is to be disclosed under this Authorization so that the Company may: 1) underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtain
reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with the Company.
This authorization shall remain in force for 30 months following the date of my signature below, and a copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to the Company at 1440 Kapiolani Boulevard, Suite 1700; Honolulu, HI 96814, Attention: Privacy Official. I understand that a revocation is not effective to the extent that any of My Providers has relied on this Authorization or to the extent that the Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to the authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information.
I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, the Company may not be able to process my application, or if coverage has been issued may not be able to make any benefit payments. I acknowledge that I have received a copy of this authorization.
Signature of Proposed Insured/Patient (or Personal Representative) Date
Pacific Guardian Tower 1440 Kapiolani Boulevard, Suite 1700 Honolulu, HI 96814-3698
Form No. UW-280 Rev. 7/04 THIS COPY TO PROPOSED INSURED
NOTICE OF PRIVACY POLICY
Information Only – No Response Necessary OverviewWe know that the privacy of your personal information is important to you. That is why we want you to understand what information we collect and how we use it. We collect and use “nonpublic personal information” in order to provide our customers with a broad range of financial products and services as effectively and conveniently as possible.
Customer Information
We may collect and maintain nonpublic personal information about you from the following sources: • Information we receive from you on applications or other forms;
• Information about your transactions with us, or others; and • Information we receive from consumer-reporting agencies.
“Nonpublic personal information” is nonpublic information about you that we obtain in connection with providing a financial product or service to you.
Sharing Information
We do not disclose any nonpublic personal information about our current or former customers to anyone, except as permitted by law. We may disclose all of the nonpublic personal information we collect, as described above, to persons or companies that perform services on our behalf, such as third party administrators, and to other financial institutions with whom we may have joint marketing agreements. Security Procedures
We restrict access to your nonpublic personal information and only allow disclosures to persons and companies as permitted by law to assist in providing products or services to you. We maintain physical, electronic, and procedural safeguards that comply with federal standards to protect your nonpublic personal information.
Disclosure of our Privacy Policy
Pacific Guardian Tower 1440 Kapiolani Boulevard, Suite 1700 Honolulu, HI 96814-3698
Form No. UW-311 7-04 THIS COPY TO PROPOSED INSURED
NOTICE OF INSURANCE INFORMATION PRACTICES
THIS NOTICE MUST BE DETACHED AND GIVEN TO PROPOSED INSURED (PARENT OR GUARDIAN IF JUVENILE)
To issue an insurance policy, and to fairly determine the cost of your insurance, we need to obtain information about you and other persons proposed for insurance. Some of that information will come from you and some will come from other sources. Two of our sources of information about you are MIB, Inc. (Medical Information Bureau) and Investigative Consumer Reports. The paragraphs below describe the services provided by these two sources. All information collected by us may in certain circumstances be disclosed to third parties without any further authorization by you.
All proposed insured persons (or their Parent or Guardian, if juvenile) have a right of access and correction with respect to the information about himself or herself, except information which relates to a claim for policy benefits or a civil or criminal proceeding.
If you wish to have a more detailed explanation of our information practices, please contact: Pacific Guardian Life Insurance Company, Underwriting Department, Pacific Guardian Tower, 1440 Kapiolani Boulevard, Suite 1700, Honolulu, Hawaii 96814-3698.
In an effort to provide better service and products to you, Pacific Guardian Life Insurance Company will use information given by you in your interview with the agent to develop marketing data. Your name will not be associated with this data in any way. If you do not want Pacific Guardian Life Insurance Company to use information obtained from you for these purposes, please contact us within ten (10) days from the date of your application. After such time, the information will be separated from your application, and we will be unable to personally identify the information with you or your application for purposes of retrieving the information.
MIB, Inc. (Medical Information Bureau) (the “Bureau”)
Information regarding any Proposed Insured's (including Additional Insured/Spouse) insurability will be treated as confidential. We or our reinsurers may, however, make a brief report thereon to the 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 any Proposed Insured's file. If there is a question as to the accuracy of the information in the Bureau's file, the Bureau may be contacted to seek a correction in accordance with the procedure 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, Massachusetts 02112. Telephone (617) 426-3660.
We or our reinsurers may also release information in our file to other life insurance companies to whom any Proposed Insured may apply for life or health insurance or to whom a claim for benefits may be submitted.
INVESTIGATIVE CONSUMER REPORTS
Depending on the size of policy applied for, we may request that an investigative consumer report about any Proposed Insured be given to us. It will be conducted by a national organization skilled in obtaining information about people. If an investigative consumer report is prepared, any Proposed Insured may request to be interviewed in connection with the preparation of this report.
The kind of information we may be seeking includes information as to the Proposed Insured’s character, general reputation, personal characteristics and mode of living. It will be obtained through personal interviews with any Proposed Insured's friends, neighbors, associates and other acquaintances.
Pacific Guardian Tower • 1440 Kapiolani Boulevard, Suite 1700 • Honolulu, HI 96814
Form No. UW-310 7-04 Appendix A This Copy to Home Office
APPENDIX A
IMPORTANT NOTICE:
REPLACEMENT OF LIFE INSURANCE OR ANNUITIES
This document must be signed by the applicant (owner) and the producer, if there is one, and a copy left with the applicant (owner).
You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements.
A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.
A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy to pay all of or part of any premium or payment due on the new policy. A financed purchase is a replacement.
You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs, and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured.
We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form.
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to
the insurer, or otherwise terminating your existing policy or contract? Yes No
Are you considering using funds from your existing policies or contracts to pay premiums due on
the new policy or contract? Yes No
If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing:
INSURED OR ANNUITANT INSURER COMPANY NAME
CONTRACT OR POLICY NO. REPLACED (R) OR FINANCING (F) R F R F R F R F
Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary, or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision.
The existing policy or contract is being replaced because:
I certify that the responses herein are, to the best of my knowledge, accurate:
Applicant’s Signature and Printed Name Date
Producer’s Signature and Printed Name Date
Form No. UW-310 7-04 Appendix A This Copy to Home Office A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense:
PREMIUMS: Are they affordable? Could they change?
You’re older—are premiums higher for the proposed new policy?
How long will you have to pay premiums on the new policy? On the old policy? POLICY VALUES:
New policies usually take longer to build cash values and to pay dividends.
Acquisition costs for the old policy may have been paid, you will incur costs for the new one. What surrender charges do the policies have?
What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage?
INSURABILITY:
If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down.
You may need a medical exam for a new policy.
Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage.
IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY: How are premiums for both policies being paid?
How will the premiums on your existing policy be affected? Will a loan be deducted from death benefits?
What values from the old policy are being used to pay premiums?
IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT: Will you pay surrender charges on your old contract?
What are the interest rate guarantees for the new contract?
Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: What are the tax consequences of buying the new policy? Is this a tax-free exchange? (See your tax advisor.)
Is there a benefit from favorable "grandfathered" treatment of the old policy under the federal tax code? Will the existing insurer be willing to modify the old policy?
Pacific Guardian Tower • 1440 Kapiolani Boulevard, Suite 1700 • Honolulu, HI 96814
Form No. UW-310 7-04 Appendix A This Copy to Applicant
APPENDIX A
IMPORTANT NOTICE:
REPLACEMENT OF LIFE INSURANCE OR ANNUITIES
This document must be signed by the applicant (owner) and the producer, if there is one, and a copy left with the applicant (owner).
You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements.
A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.
A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy to pay all of or part of any premium or payment due on the new policy. A financed purchase is a replacement.
You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs, and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured.
We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form.
Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to
the insurer, or otherwise terminating your existing policy or contract? Yes No
Are you considering using funds from your existing policies or contracts to pay premiums due on
the new policy or contract? Yes No
If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing:
INSURED OR ANNUITANT INSURER COMPANY NAME
CONTRACT OR POLICY NO. REPLACED (R) OR FINANCING (F) R F R F R F R F
Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary, or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision.
The existing policy or contract is being replaced because:
I certify that the responses herein are, to the best of my knowledge, accurate:
Applicant’s Signature and Printed Name Date
Producer’s Signature and Printed Name Date
Form No. UW-310 7-04 Appendix A This Copy to Applicant A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense:
PREMIUMS: Are they affordable? Could they change?
You’re older—are premiums higher for the proposed new policy?
How long will you have to pay premiums on the new policy? On the old policy? POLICY VALUES:
New policies usually take longer to build cash values and to pay dividends.
Acquisition costs for the old policy may have been paid, you will incur costs for the new one. What surrender charges do the policies have?
What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage?
INSURABILITY:
If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down.
You may need a medical exam for a new policy.
Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage.
IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY: How are premiums for both policies being paid?
How will the premiums on your existing policy be affected? Will a loan be deducted from death benefits?
What values from the old policy are being used to pay premiums?
IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT: Will you pay surrender charges on your old contract?
What are the interest rate guarantees for the new contract?
Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: What are the tax consequences of buying the new policy? Is this a tax-free exchange? (See your tax advisor.)
Is there a benefit from favorable "grandfathered" treatment of the old policy under the federal tax code? Will the existing insurer be willing to modify the old policy?
UW-260 (Rev. 4/05)
1440 Kapiolani Boulevard, Suite 1700 • Honolulu, HI 96814 Phone: (808) 955-2236 • Fax: (808) 942-1280
CONDITIONAL RECEIPT AGREEMENT
THIS CONDITIONAL RECEIPT AGREEMENT IS NOT VALID FOR MORE THAN $500,000.
This Conditional Receipt Agreement (“Agreement”) provides a limited amount of life insurance coverage, for a limited period of time, subject to the terms and conditions of this Agreement. This Agreement may not be given if the insuring age of any proposed insured is under 15 days or over 70 years of age.
A. Health Questions – Have you: Proposed Insured Additional Insured
1. Had or been treated for heart disease, stroke, cancer, or alcohol or drug dependence or
abuse within the past 5 years? Yes No Yes No
2. Been admitted or medically advised to be admitted to a hospital or other licensed health care facility, had surgery performed or recommended, or been medically advised to have
any diagnostic testing that was not completed in the past ninety (90) days? Yes No Yes No 3. Been diagnosed as having Acquired Immunodeficiency Syndrome (AIDS) or AIDS
Related Complex (ARC)? Yes No Yes No
If any of the above questions are answered YES OR LEFT BLANK: (1) no agent or representative of the Pacific Guardian Life Insurance Company, Limited (“Company”) is authorized to accept money; and (2) NO COVERAGE will take effect under this Agreement. No agent is authorized to alter or waive any of the conditions of this Agreement.
B. Conditions and Limitations
Limited Amount: The limited amount of life insurance which may become effective under this Agreement on each person proposed for insurance shall not exceed the lesser of: (1) the amount of insurance requested in the application; or (2) $500,000 minus all insurance on such proposed insured’s life in force with Pacific Guardian Life under any policies or conditional receipts. Life insurance includes any benefits for accidental death. Conditions:
• A minimum advance payment is required in an amount equal to the full first premium according to the mode of premium payment selected for the amount of insurance which may become effective prior to the policy delivery.
• Any check given in payment must be honored when first presented to the bank.
• All medical examinations and tests required by the Company’s initial underwriting requirements must be completed and received at its Home Office within 60 days from the date of the application.
• If any person proposed for insurance dies by suicide or by intentionally self-inflicted injury or if the application or this Agreement contains any material misrepresentations, then the Company’s liability under this Agreement is limited to a refund of the premium paid.
• On the effective date as defined below, all persons proposed for insurance must be acceptable risks to the Company: (1) under its rules, limits and standards for the plan; and (2) for the amount applied for without modification; and (3) at the rate of premium paid.
Date Coverage Begins: If all conditions in this Agreement have been fulfilled exactly, limited coverage, subject to the limit on the amount of life insurance set forth above in the section “Limited Amount”, may begin on the later of: (a) the date of the properly completed and signed application; or (b) the date of completion of all medical examinations, tests and other evidence required by the Company on all proposed insureds.
Termination Date: Coverage under this Agreement, if it has begun, will terminate automatically on the earliest of: (1) 60 days from the date of the properly completed and signed application; (2) the date the insurance takes effect under the policy applied for; (3) the date an insurance contract other than as applied for in the application is offered to the Proposed Owner; or (4) the Company mails you a letter notifying you: (a) that it has declined to issue you a policy; or (b) that it will not provide life insurance coverage on a prepaid basis.
If insurance is declined or the policy is not accepted, any premium paid will be returned to the Owner. If the policy is accepted, any premium paid will be credited to the premiums due under such policy.
I have read the terms of this Agreement. I understand that the insurance applied for will not be effective unless and until all conditions of this Agreement are met. I certify and affirm that the answers given by me in response to the Health Questions in Section A are true and correct. I understand and agree that there will be no insurance coverage payable under this Conditional Receipt Agreement if my answers are incorrect and/or fraudulent.
Received in connection with the application on the life/lives of _______________________________________________________________________ the sum of $__________________ from ________________________________________________________________________________________ Signature of Proposed Insured Date Signature of Proposed Additional Insured Date (Parent or Guardian if under 18 years of age)
Signature of Owner Date Signature of Licensed Agent Date
All checks must be made payable to Pacific Guardian Life Insurance Company, Limited. Do not make checks payable to the agent or leave the payee blank.
Certification of
Non-Hard Copy Illustration Application
I, Agent, certify that I displayed a computer screen illustration for
that
that complies with state requirements and for which no hard copy was furnished. The illustration was
based on the following information:
I, Applicant, acknowledge that I viewed a computer screen illustration based on the information that
was stated above. No hard copy of the illustration was furnished. I, Applicant, understand that an
illustration conforming to the policy as issued will be provided to me no later than the time the policy
is delivered.
1. Gender: ■ Male ■ Female
2. Date of Birth:
3. Underwriting or Rating Class:
4. Tobacco Use: ■ Yes ■ No
5. Plan of Insurance
(e.g., Product name):
6. Initial Death Benefit Amount:
7. Riders Being Applied For:
8. Death Benefit Option: ■ Option 1 ■ Option 2
Agent’s Name (Please Print) Applicant’s Signature
Agent’s Signature Date
F o rm No. AG-477 Rev. 7 - 0 4 Pacific Guardian Life, Pacific Guardian To w e r, 1440 Kapiolani Boulevard, Honolulu, Hawaii 96814
Please return for processing to: INDIVIDUAL LIFE ADMINISTRATION
1440 Kapiolani Boulevard, Suite 1700 • Honolulu, HI 96814-3698 (800) 432-3306 • Email: [email protected]
BANK DRAFT AUTHORIZATION FORM
Pacific Guardian Life can help take some of the hassle out of paying your insurance premiums with our Monthly Bank Draft
method of payment. Payments can be deducted from your checking/savings account every month. The deduction will appear on your checking/savings account statement.
Please fill in the information below, sign and return this form with a voided check from your checking/savings account. If you have any questions, please contact our Client Relations Department at 1-800-432-3306 or you can email your inquiries to [email protected].
If bank account holder is different from policyowner indicate relationship
The undersigned has authorized Pacific Guardian Life Insurance, Company, Limited of Honolulu, Hawaii to pay premiums on the numbered policy/policies, as indicated above, as they become due and to charge such amounts to my account. If, at any time, I do not have on deposit in said bank available funds sufficient to pay such checks, the arrangement shall be automatically discontinued and, in that event, the insured or premium payer shall be required to pay premiums in a manner provided in the policy by paying a pro rata premium, if necessary, to the next premium due date.
IMPORTANT: PLEASE ATTACH A VOIDED PERSONALIZED CHECK–Check one: o Checking o Savings
Authorization to honor checks drawn by Pacific Guardian Life Insurance Company, Limited, Honolulu, Hawaii
As a convenience to me, I hereby request and authorize you to pay and charge my account checks drawn on my account by and payable to the order of PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LIMITED, provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that your rights in respect to each such check shall be the same as if it were a check drawn on you and signed personally by me. This authority is to remain in effect until revoked by me, in writing, and until you actually receive such notice, I agree that you shall be fully protected in honoring any such check. I further agree that if any such check be dishonored, whether with or without cause, and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance. The undersigned requests the bank named below to honor debit entries, either by electronic or paper means, to the bank account number below and payable to Pacific Guardian Life.
Bank Routing Number & Account Number: Name of Bank Depositor:
Bank Address:
City: State: Zip:
x Date x Date
*Signature or Signatures must be the same as on signature card at bank and if a company account, the name of the account must be shown. Print Name (Account Holder) Print Name (Account Holder)
Form No. PS118 Rev. 03/09
Policy Number Print Name of Insured
Premium Payment Amount Loan Repayment Amount Starting Date Home Office Use Only
