ADV-1-254IBP & 556IBP & CCLB-Rider
Wouldn’t a check be
better than a get well card.
Southwest Service Life Insurance Company
(Home Office)Fort Worth, Texas
Permanent Critical Illness Insurance
This exclusive Southwest Service coverage is designed to pay in a lump sum, the percentage of your whole life insurance death benefit if you are ever diagnosed with one
of the following covered conditions while this policy is in force:
we pay
Terminal Illness . . . 100%
Major Heart Surgery . . . .50%
Heart Attack . . . .50%
Renal Failure . . . .50%
Major Organ Transplant . . . .50%
Stroke . . . .50%
Cancer (life threatening) . . . .50%
Breast Cancer . . . .30%
Prostate Cancer . . . .30%
Death from any cause is a 100% benefit
(except suicide during the first two years)
What is Critical Illness Coverage and how does it work?
Upon the first diagnosis of any one of the covered conditions listed above, made on or after the 30th day from the effective date of the policy, except for terminal illness which pays the full face amount of the policy, Southwest Service will pay the percentage of the face amount of the life policy in a lump sum directly to the insured. These listed covered conditions are defined in the actual rider attached to your policy.After payment of any one of these Living Benefits, the face amount of the policy will be reduced by the amount of this payment and the remaining portion of the death benefit will be paid upon the death of the insured. A notice will be sent to the owner of the policy at the time of the Living Benefit payment, setting out the amount of the benefits paid, the effect of the benefit payment on the death benefit and the amount of benefits remaining on the policy.
Why would I need this type of insurance coverage?
Almost everyone knows someone who has experienced a critical illness of some kind and survived physically, but then be left in financial ruin. Critical illness insurance is designed to help people through the financial challenges associated with survival of a critical illness.
Wouldn’t a check be better than a get well card?
Living Benefits are paid directly to you. You choose how to spend the benefit at a time when you and your family may need extra cash the most. Here are a few of the things the money can be used for:
The money is yours to use as you see fit and it is paid in addition to any other insurance you may have, including MEDICARE.
Replacing a paycheck
Credit Card payments
Co-pays & Deductibles
Home & Car expenses
Home Health
care needs
House payment or rent
Car or Truck payments
Childcare expenses
Nursing Home Care
Housekeeping
expenses
Groceries and utilities
Assisted Living Care
Keep your
business going
Lost income
Non-covered
treatments
Approximately
780,000
people suffer strokes each year*
Approximately
1.2
people suffer heart attacks
million
each year.
More than
1.4
new cancer cases were
million
estimated for diagnosis in 2009.
Why
c
ritical
Illness Coverage?
* Statistic Sources.
American Heart Association, Heart and Stroke Statistical Update, 2008. American Cancer Society,
Cancer Facts & Figures, 2009.
ADV-2-254IBP & 556IBP & CCLB-RIDER
Survival Rates are Up!
Advanced medical technology is allowing many more people to survive critical illnesses that would have been fatal in the past:
• Between 1994 and 2004, the death rate declined approximately 31% for heart attacks and almost 24% for strokes. (Source: American Heart Association, Heart and Stroke Statistical Update 2008)
• The possibility of surviving a critical illness before age 65 is almost twice as great as dying. (Source: National Center for Health Statistics)
What if I experience more than one of the
Covered Critical Conditions?
Only one of the covered Critical Condition Living Benefits can be paid to an insured during their lifetime. Once a Living Benefit is paid, the face amount of the life insurance is reduced by the amount of the Living Benefit check. The remaining death benefit will be paid to your designated beneficiary at death. The Living Benefit is not considered a loan, therefore you do not have to repay the money or pay interest on this benefit.
Can I outlive these benefits? Do they stop at a certain age?
This is a whole life policy without cash values. It is not health insurance or a term life insurance policy that only runs for a limited time. Once the policy is issued, it is in force until you die or you let it lapse for non payment of premiums. It is permanent life insurance and the extra Critical Illness Benefits stay in force for as long as the policy is in force, regardless of your age.Critical Illness Family Coverage
Permanent whole life policy with extra Critical Illness benefits can be written on you and your spouse or your whole Family. Once your policy is approved and issued by the Home Office, upon the first diagnosis of any one of the covered conditions listed below, made on or after the 30th day from the effective date of the policy, Southwest Service will pay the percentage of the face amount of the policy in a lump sum directly to the insured except for terminal illness which pays 100% of the face amount of the policy.
Death from any cause is a 100% benefit
(except suicide during the first two years)
Do I have to die from one of these Critical Conditions for the
life insurance benefits to be paid?
The life insurance benefit will be paid to your beneficiary for death from any cause, except for suicide during the first two years of the policy.
Remember your whole life policy with Critical Illness benefits is permanent life insurance; it stays with you as long as you live, and when you need it most as you get older, as long as you pay the premiums.
Tax Treatment of Accelerated Living Benefits
Unlike a death benefit, living benefits may be taxable. You should consult with a tax advisor as to the taxability of any living benefit you receive.
Survival Rates are
UP!
Not because you’ll die,
because you’ll
carryon
5.7 million
stroke survivors are alive today*
ADV-3-254IBP & 556IBP & CCLB-RIDER
* Statistic Sources.
American Heart Association, Heart and Stroke Statistical Update, 2008. American Cancer Society,
Cancer Facts & Figures, 2009.
A Living Benefit Insurance Policy
Terminal Illness . . . .100%
Major Heart Surgery . . . 50%
Heart Attack. . . 50%
Renal Failure . . . 50%
Major Organ Transplant. . . 50%
Stroke . . . 50%
Cancer (life threatening) . . . 50%
Breast Cancer. . . 30%
Prostate Cancer. . . 30%
Southwest Service Life Insurance Company
Mail Policy to
o
Policyholdero
Agent ADB-74 AGEForm No.APP-L-254IBP & 556IBP & CCLB- RIDER
ANY MISSTATEMENTS AS TO HEALTH OR PHYSICAL CONDITION, THAT SHALL MATERIALLY INCREASE THE RISK ASSUMED, SHALL CAUSE THIS POLICY TO BECOME NULL AND VOID WITHIN THE CONTESTABLE PERIOD.
AGREEMENT: I hereby apply to Southwest Service Life of Fort Worth, Texas, for a policy solely and entirely in reliance upon the written answers to the foregoing questions and I expressly agree on behalf of myself and any person who shall claim any interest in any policy issued on this application as follows: (1) All statements and answers contained herein are full, complete and true to the best of my knowledge and belief. (2) The insurance hereby applied for shall not be considered in force until a policy is issued and manually received and accepted by me and the full first premium paid thereon while the proposed Insured’s health and other conditions remain as described in this application. (3) On behalf of myself, each of us, and of every person who shall have or claim an interest in any policy issued as a result of my application, I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, the Medical Information Bureau, or other organization, institution or person, that has any records or knowledge of me or my health, to give Southwest Service Life Insurance Company, or its reinsurers, any such information. I also agree that all provisions of law prohibiting or exempting physicians or hospital officials from testifying or disclosing information are waived in favor of Southwest Service Life Insurance Company. A photocopy of this authorization is to be considered as valid as the original. I UNDERSTAND THIS POLICY HAS NO CASH OR LOAN VALUES.
Dated at _______________________________________ Signed ____________________________________________________________
CITY & STATE PROPOSED INSURED
On ______________________________ , 20 __________ Signed ____________________________________________________________
MONTH DAY APPLICANT IF OTHER THAN PROPOSED INSURED
Agent ________________________________No. ______ __________________________________________________________________
RELATION OF APPLICANT TO PROPOSED INSURED
LIFE INSURANCE APPLICATION
Policy Form No. APP-L-254IBP & 556IBP & CCLB- RIDERTelephone Number ( _______ ) _________________________________________ Daytime Telephone Number ( _______ ) __________________________________
Address of proposed insured
Address _____________________________________________________________ City & State _________________________________________ Zip______________
To whom should premium notices be sent?
Name__________________________________SS# _________________________ Address _____________________________________________________________ City & State _________________________________________Zip ______________ Name of Family Physician? ______________________________________________ Address _____________________________________________________________ City _______________________________________________State ____________
(a) Are you now in good health and without physical or mental defect or deformity? ...
o
YESo
NO (b) Will the life insurance being applied for replace or change any existing life insurance or annuity? ...o
YESo
NO (c) Have you been hospitalized within the past three years? (if YES, detail below) ...o
YESo
NO ____________________________________________________________________________________________________________________ (d) List all prescription medicines currently being taken by the applicant. _______________________________________________________ ____________________________________________________________________________________________________________________PLEASE PRINT
SPECIAL REQUEST POLICY NUMBER
AGENT NUMBER CWA
BILLING MODE
PROPOSED INSUREDS SEX DATE OF BIRTH
MO. DAY YR. HT. WT. INITIAL FACE AMOUNT SOCIAL SECURITY NUMBER
Southwest Service
Life Insurance
Company
(A Stipulated Premium Company) Fort Worth, Texas
1. 2.
Occupation
_________________________________
Mode of Premium Payment (check): o Annual o Semi-Annual o Quarterly o Monthly o Monthly Bank Draft
Premium: $
_________________________________
1st Insured Primary Beneficiary _________________________________ Address ____________________________________________________ City/State/Zip _______________________________________________ SS# _______________________________________________________ Contingent Beneficiary _______________________________________ SS# _______________________________________________________ 2nd Insured Primary Beneficiary ________________________________ Address ____________________________________________________ City/State/Zip _______________________________________________ SS# _______________________________________________________ Contingent Beneficiary _______________________________________ SS# _______________________________________________________
If any of the following questions are answered “
YES
”, coverage “
CANNOT
” be issued.
1. Has any applicant
EVER
been diagnosed with or treated for
insulin dependent diabetes or had any type of amputation
caused by disease or
EVER
received or been advised to
have an organ transplant? ...
o YES o NO2. Has any applicant
EVER
been HIV positive, or
EVER
had or been treated for AIDS or ARC? ...
o YES o NO3. Has any applicant
EVER
been diagnosed with or
treated for Alzheimer’s disease, Cirrhosis
of the liver, or had dialysis? ...
o YES o NO4. Has any applicant
EVER
been diagnosed or treated for
congestive heart failure, heart attack, stroke, internal
cancer, malignant melanoma, renal failure, leukemia or
Hodgkin’s disease? ...
o YES o NO5. Is any applicant currently hospitalized or confined to a
nursing facility? ...
o YES o NO6. Is any applicant bedridden or confined
to a wheelchair? ...
o YES o NO7. In the past five years, has any applicant been
diagnosed or treated for mental illness,
alcoholism, or drug addiction? ...
o YES o NO 8. In the past five years, has any applicant used oxygen at home to assist in breathing?...
o YES o NOCritical Illness Insurance
Male and Female - same rate.
Policy Fee: Annually $30.00, Semi-annually $15.00, Quarterly $7.50, Monthly $2.50
Minimum amount of coverage sold Per Applicant - $5,000. Maximum amount of coverage - $25,000 per applicant.
Rates include ADB (2 times base amount) through age 74 (NO ADB Benefits are available ages 75-80)
AUTHORIZATION TO HONOR CHECKS DRAWN BY
THE SOUTHWEST SERVICE LIFE INSURANCE COMPANY, FORT WORTH, TEXAS 76182
To: ______________________________________________________________________________________________________ Bank Address: _____________________________________________________________________________________________ Bank Number: _____________________________________________________________________________________________ As a convenience to me, I hereby request and authorize you to pay and charge to my account checks drawn on my account by and payable to the order of the Southwest Service Life Insurance Company, Fort Worth, Texas. 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 fullypro-tected 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.
Date Account No. Signature EXACTLY as it appears on Bank Records Form No. 254IBP and 556IBP & CCLB-Rider
Southwest Service Life Insurance Company
Premium Rates for L-254 with CCLB Rider
Rates per $1,000 of Face Amount
Age AnnualPolicy MBD Monthly1-21 13.25 1.20 1.33
22 13.92 1.25 1.39
23 14.42 1.30 1.44
24 14.95 1.35 1.49
25 15.51 1.40 1.55
26 16.07 1.44 1.61
27 16.67 1.50 1.66
28 17.31 1.55 1.73
29 18.00 1.62 1.81
30 18.74 1.68 1.87
31 19.53 1.76 1.95
32 20.37 1.84 2.04
33 21.26 1.91 2.12
34 22.20 2.00 2.22
35 23.20 2.09 2.32
36 24.27 2.18 2.43
37 25.43 2.29 2.54
38 26.65 2.40 2.66
39 27.94 2.52 2.79
40 29.27 2.64 2.93
41 30.75 2.77 3.07
42 32.25 2.91 3.22
43 33.82 3.05 3.39
44 35.46 3.20 3.55
Southwest Service Life Insurance Company
Premium Rates for L-556 with CCLB Rider
Rates per $1,000 of Face Amount
Age AnnualPolicy MBD Monthly45 37.19 3.35 3.72
46 39.00 3.51 3.90
47 40.88 3.68 4.09
48 42.90 3.86 4.29
49 45.00 4.05 4.50
50 47.20 4.25 4.72
51 49.54 4.46 4.95
52 51.99 4.68 5.20
53 54.59 4.91 5.46
54 57.32 5.16 5.73
55 60.22 5.41 6.02
56 63.27 5.69 6.33
57 66.50 5.98 6.65
58 69.94 6.29 6.99
59 73.58 6.62 7.36
60 77.43 6.97 7.74
61 81.51 7.34 8.16
62 85.83 7.72 8.58
63 90.40 8.14 9.04
64 95.23 8.57 9.52
65 100.34 9.03 10.03 66 105.79 9.52 10.58 67 111.60 10.04 11.16 68 117.80 10.60 11.79 69 124.39 11.19 12.44 70 131.38 11.82 13.14 71 138.82 12.50 13.88 72 146.75 13.20 14.67 73 155.19 13.96 15.52 74 164.12 14.77 16.41 75 169.52 15.26 16.95 76 179.56 16.16 17.96 77 190.27 17.13 19.03 78 201.29 18.12 20.13 79 213.79 19.24 21.38 80 227.13 20.45 22.72 Policy reserves are based on 1956 Chamberlain Mortality Table at 3 1/2%
ADV-4-254IBP & 556IBP & CCLB-Rider
Definitions
The benefit amount set out herein will be paid to you upon proof of the occurrence of any one of the covered conditions defined below. A covered condition must first manifest itself on or after the 30th day following the effective date as set out in this Rider, except for Terminal Illness which must first manifest itself after the effective date of this Rider. The policy and Rider must be in force at the time of the occurrence. If a condition is
not listed in this section it is not covered under this Rider.
(a) Terminal Illness: Advanced or rapidly progressing incurable disabling terminal illness where, based on our investigation, the life expectancy is no greater than twelve (12) months.
(b) Life-Threatening Cancer: The manifestation of a malignant tumor (a tumor which is not encapsulated and has properties to infiltrate and cause metastasis) including leukemia and Hodgkin’s disease (except Stage 1 of Hodgkin’s disease). The disease must be supported by histopathological evidence of malignancy.
(c) Heart Attack: Death of a portion of the heart muscle (myocardium) resulting from a blockage of one or more coronary arteries.
(d) Stroke: Any acute cerebral vascular accident producing neurological impairment and resulting in paralysis or other measurable neurological deficit persisting for at least thirty (30 days). After a neurological deficit has persisted for at least thirty (30) days, the Eligibility Date will be the initial date of loss. This definition of stroke will specifically exclude Transient Ischemic Attacks and attacks of Vertebrobasilar Ischemia. (e) Renal Failure: End stage renal failure presenting as chronic irreversible failure of both kidneys to function, as a result of which regular renal
dialysis is instituted or renal transplantation is carried out.
(f) Major Organ Transplant: The clinical evidence of major organ(s) failure, which require the malfunctioning organ(s) or tissue of the insured to be replaced with an organ(s) or tissue from a suitable human donor (excluding the insured) under generally accepted medical procedures. The organs and tissues covered by this definition are limited to: liver, kidney, lung, entire heart or bone marrow. In order for the Major Organ Transplant to be covered under this Policy, the Insured must be registered by the United Network of Organ Sharing (UNOS). In order for the Bone Marrow Transplant to be covered under this Policy, the Insured must be registered by the National Marrow Donor Program (NMDP). (g) Major Heart Surgery: (i) Coronary by-pass surgery, the actual undergoing of coronary by-pass surgery (either saphenous vein or internal
mammary graft) following an unequivocal recommendation by a consulting cardiologist for the treatment of coronary disease. (ii) Heart Valve Replacement, the actual undergoing of the total replacement of one or more heart valves for the treatment of disease. Heart valve repair and valvotomy are specifically excluded. (iii) Aorta Surgery, the actual undergoing of surgery for disease of the aorta needing excision and surgical replacement of the diseased aorta with a graft. For the purpose of this definition, aorta means the thoracic and abdominal aorta but not its branches. Traumatic injury of the aorta is excluded. The company reserves the right to withhold payment pending the satisfactory evidence that the above procedures have been carried out.
(h) Breast Cancer: A cancer that forms and/or originates in the tissues of the breast and which is manifested by the presence of a malignant tumor characterized by the uncontrolled and abnormal growth and spread of malignant cells and invasion of normal tissue within the breast and the insured receives definite treatment for breast cancer.
(i) Prostate Cancer: A cancer that forms and/or originates in the tissues of the prostate and which is manifested by the presence of a malignant tumor characterized by uncontrolled and abnormal growth and spread of malignant cells and invasion of normal tissue within the prostate, and the insured receives definitive treatment for prostate cancer.
(j) Medical Opinion: The written opinion of a Physician or Surgeon who is a legally qualified licensed Physician, other than Insured or a member of the family related to the Insured, who would be practicing within the scope of his/her license.
Additional features of SWSL’s Critical Illness Policy
ACCIDENTAL DEATH BENEFIT RIDER:
For ages 1 through 74, the face amount of the policy will be paid, plus an amount equal to twice that amount, For a TOTAL PAYMENT OF TRIPLE THE FACE AMOUNT OF YOUR POLICY (ADB) not available for ages 75 and older.
The accidental Death Coverage is included in the policy at No Additional Premium from ages 1-74.
Southwest Service Life Insurance Company • PO Box 982005, Fort Worth, TX 76182
Your Plan … Death Benefit … $______________
Southwest Service LIFE INSURANCE COMPANY CONDITIONAL RECEIPT: THIS RECEIPT DOES NOT PROVIDE ANY INSURANCE UNTIL ITS CONDITIONS ARE MET:
Received from __________________________________________________ on this ____________ day of ______ 20 ____ , the sum of $ __________________ the correct first premium contained in the application subject to the following conditions:
(1) The Applicant is acceptable to and approved by the Company as insurable under the Company’s underwriting rules. (2) If any Applicant is not acceptable to and approved by Company, as above specified, then no insurance shall become effective on any Applicant and the Company shall incur no liability hereunder except to return the amount shown by this receipt. (3) The Company is not liable for any loss whatsoever sustained before a policy is actually issued by the Company and delivered to the applicant and the applicant’s health remains as
described in the application, and the Company is then liable only as provided and limited in the policy.
Signature of Soliciting Agent ______________________________________________________________________________________
All premium checks must be made payable to the Company. Do not make payable to the agent or leave payee blank.
