APPLICATION FOR INSURANCE. 1. Full Name (print) Phone Number: 2. (Address) (City) (State) (Zip)

FIRST

CATHOLIC

SLOVAK

UNION

OF

THE

U.S.A

AND

CANADA

      ( A Fraternal Benefit Society) 

6611

Rockside

Road,

Independence,

Ohio

44131

‐

2398

216

‐

642

‐

9406

www.fcsu.com

Is applicant a member of the First Catholic Slovak Union  Yes(  )    No(  )   

If not, apply for membership.  Branch ________            E‐mail Address: ______________________________   

1.     Full Name (print) __________________________________________________________   Phone Number: _____________________ 

2.     ____________________________________________________________________________________________________________ 

(Address)            (City)             (State)             (Zip)   

3. Birth date:  Month ____________ Day ______ Year _______ Birthplace __________________________________________________   

4.     Sex    M(  )    F(  )     Social Security No ____________________    Height ____ft  ____in    Weight ________   

5.     Occupation ___________________________________       6.  Employer _______________________________________________   

  7a.   Name and Address of Beneficiary ________________________________________________________________________________        

        __________________________________________________________  Relationship to Applicant ____________________________   

7b.   Name and Address of Contingent Beneficiary  _______________________________________________________________________             

        ____________________________________________________________________________________________________________ 

7c.   Owner, if other than proposed insured __________________________  Relationship to Applicant  ____________________________ 

8.     Is this insurance intended to replace or change any insurance or Annuity now in force?  Yes(  )    No(  ) 

         If yes, give details _____________________________________________________________________________________________ 

9.     Within the past 5 years, has Proposed Insured used tobacco in any form?  Yes(  )    No(  )   

10a. Within the past 5 years, has Proposed Insured been hospitalized; or received medical treatment or advice for any illness, disease,           injury or physical condition?  Yes(  )    No(  ) 

10b. Does Proposed Insured have any physical or mental handicaps?  Yes(  )    No(  ) 

10c. Give details of YES answers to 9, 10a, and 10b (Tobacco use; Illness or handicap; dates, duration; physicians; and/or hospital)          ____________________________________________________________________________________________________________   

        ____________________________________________________________________________________________________________ 

11.   Plan of Insurance ____________________________________        Amount of Insurance $________________          Rider/s ____________________________________________       Premium $________________          Method of Payment        Single Premium(  )    Annual(  )    Semi‐Annual(  )    Quarterly(  ) 

I AGREE THAT NO INSURANCE SHALL TAKE EFFECT UNLESS AND UNTIL (1) the first premium shall have been paid; (2) a certificate is delivered to the 

applicant during the Proposed Insured’s lifetime; (3) the health of the Proposed Insured is as described in the application to the best of my 

knowledge and belief; (4) the Proposed Insured has been obligated in due form; and (5) all requirements of the Constitution and Bylaws have been 

complied with.     

Signed at __________________________________ this ________ day of ________________ 20____   

______________________________________________       _______________________________________________________________ 

Signature of Agent or Proposer         Proposed Insured’s Signature (Parent or Guardian if applicant is under age 16)   

Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application containing a false or 

deceptive statement is guilty of insurance fraud.   

AUTHORIZATION 

I hereby authorize any licensed physician; medical practitioner, hospital, clinic  other medical or medically related facility, insurance company, MIB, 

Inc (“MIB”) or other organization, institution or person that has any record or knowledge of me or my health, to give to First Catholic Slovak Union 

or its representatives, or bearer, or its reinsurers any such information.  Authorization is valid for no longer than thirty months.  A photographic 

copy of this authorization shall be as valid as the original.     

Date ______________________________ 20____   

_____________________________________________     _______________________________________________________________ 

Signature of Agent or Proposer         Proposed Insured’s Signature (Parent or Guardian if applicant is under age 16)   

SF‐08 CT 

       APPLICATION FOR INSURANCE

      USE THIS FORM FOR         THE FOLLOWING AMOUNTS:  Age      Amounts Under  0‐50    $5,001 

        or 

First Catholic Slovak Union of the

United States of America and Canada

(Herein called FCSU)

[6611 Rockside Road, Suite 300, P. O. Box 318013, Independence, OH 44131-8013]

1-800-JEDNOTA or (216) 642-9406

A Fraternal Benefit Society

Addendum to Life Insurance Application

Form AJ-08

The following questions are added as an addendum to the application form noted above and are

part of the application:

1.

Does any person named as Beneficiary or Contingent Beneficiary lack an insurable

interest* in the person to be insured?

Yes ___ No ___ If yes, please explain ___________________________________

2.

Is any portion of the premium on the policy applied for, to be paid in whole or in part

through an assumption; and/or forgiveness of a loan used to fund premiums?

Yes ___ No ___ If yes, please explain ___________________________________

*Insurable interest - A connection by blood of the beneficiary to the insured or an

economic connection under which the beneficiary stands to suffer financial loss by

reason the death of the insured.

CT-3

Party

FIRST CATHOLIC SLOVAK UNION

OF THE USA & CANADA

(Herein called FCSU)

6611 Rockside Road, Suite 300

Independence, OH 44131-8013

Designation of Third Party Notice

You will receive notice if your policy is about to lapse (terminate) because you have not

paid premiums. We will be glad to send a copy of this notice to another person, if you

would like. That person will not be responsible for payment of the premium, and you will

always receive your own copy of the notice. If you want an extra copy sent to another

person, please give us that person’s name and address. While your policy is in force,

you may make such designation or change an existing designation, by submitting a

written notice to us containing the name and address of the third-party designee.

1. As the Owner of a life insurance policy, I hereby appoint the following individual/s

to receive a copy of any future notice of cancellation, lapse or non-renewal of the

policy referenced below.

2. If the designated third party/s wishes to cancel receipt of notice from the Society,

the third party/s will notify, in writing, both the Society and the Owner.

3. If the Owner wishes to rescind an appointment/s, written notification will be sent

by the Owner to the Society.

THIRD PARTY DESIGNATION

1. Policy Number:

Date:

Third Party Notice, Designee:

(Print Name)

Address:

Phone Number:

2. Policy Number:

Date:

Third Party Notice, Designee:

(Print Name)

Address:

Phone Number:

3. By my signature below, I decline to designate a third party/s.