Secure Step Life Insurance
Do you have enough life insurance? If not, you’re not alone. Studies show that 93% of Americans say they need it, too. Grange makes it easy to cover all of your insurance needs, including life insurance. Secure Step Life Insurance gives you peace of mind and provides lifetime financial protection for your loved ones.
With this simple application, it’s easy to take the next step in securing your family’s future. With just 2 medical questions, your policy can be approved today!
Secure Step
Life Insurance
Application
Life Insurance Binding Receipt
Grange Life Insurance Company671 South High Street, P.O. Box 1218 • Columbus, Ohio 43216-1218 • (800) 399-3797
Received from _______________________________________ Date________________________
p
the sum of $____________________________ being the payment of one modal premium, orp
if monthly, authorization to draft my first monthly premium using Easy Pay payment plan.The insurance requested will start on the date of this application only if: (a) the first premium is paid (check or draft must be honored upon presentation or insurance is void); (b) questions 1, 2, and 4 are answered “No”; (c) the proposed insured is a citizen or permanent resident of the United States; and (d) the health of the proposed insured is as described in the
application of coverage. Should the application be declined, or not approved as applied for within sixty days from the date of this Receipt, this Receipt shall be void, and any amount paid will be refunded.
Agent’s Signature ____________________________ Agent’s Phone Number________________
Make check payable to Grange Life Insurance Company. Do not make check payable to the agent, agency or leave payee line blank.
L-3-54 (1/2010) MN
Take the next step in securing your family’s future...
A Secure Step Life Insurance policy is a permanent life insurance plan that provides peace of mind with lifetime financial protection. You can rest easy knowing that your payments never change and the cash value in your policy is guaranteed – regardless of what happens in the market.When you own a Secure Step Life Insurance policy:
• Most importantly, your loved ones are financially protected
• Your premiums/payments never change
• Your cash value is guaranteed
• You own a permanent policy that never needs to be renewed or converted
• You may be able to save more on your Grange auto policy with a qualifying Life policy
After you complete the application and provide the modal premium or Easy Pay Authorization, your coverage* is effective immediately. You should expect to receive your policy in the mail in about 2 weeks.Here’s what you’ll pay:
Payment mode: ______________________ Payment amount: $________________
Congratulations on taking the Secure Step for your family’s future!
*Coverage is subject to the terms of your policy contract and the Binding Receipt below.
During the first two policy years, this policy will pay a death benefit equal to 400% of the total annualized premium based
on monthly mode. The policy will pay the specified amount minus the death benefit during the first two years of the policy contract if death is as a result of an accident. After that, the death benefit will be the specified amount.
Policy Year Specified Amount
1 & 2 400% of the total annualized premium based on monthly mode; accidental death pays
specified amount minus the death benefit.
3 + $_______________
Notice Concerning Policyholder Rights in an Insolvency
Under the Minnesota Life and Health Insurance
Guaranty Association Law
If the insurer that issued your life, annuity, or health insurance policy becomes impaired or insolvent, you are entitled to compensation for your policy from the assets of that insurer.
The amount you recover will depend on the financial condition of the insurer.
In addition, residents of Minnesota who purchase life insurance, annuities, or health insurance from insurance
companies authorized to do business in Minnesota are protected, SUBJECT TO LIMITS AND EXCLUSIONS, in the
event the insurer becomes financially impaired or insolvent. This protection is provided by the Minnesota Life and Health Insurance Guaranty Association.
Minnesota Life and Health Insurance Guaranty Association 4760 White Bear Parkway, Suite 101, White Bear Lake, MN 55110
The maximum amount the guaranty association will pay for all policies issued on one life by the same insurer
is limited to $500,000. Subject to this $500,000 limit, the guaranty association will pay up to $500,000 in life insurance death benefits, $130,000 in net cash surrender and net cash withdrawal values for life insurance, $500,000 in health insurance benefits, including any net cash surrender and net cash withdrawal values, $250,000 in annuity net cash surrender and net cash withdrawal values, $410,000 in present value of annuity
benefits for annuities which are part of a structured settlement or for annuities in regard to which periodic annuity benefits, for a period of not less than the annuitant’s lifetime or for a period certain of not less than ten years, have begun to be paid on or before the date of impairment or insolvency, or if no coverage limit
has been specified for a covered policy or benefit, the coverage limit shall be $500,000 in present value.
Unallocated annuity contracts issued to retirement plans, other than defined benefit plans, established under
section 401, 403(b), or 457 of the Internal Revenue Code of 1986, as amended through December 31, 1992, are covered up to $250,000 in net cash surrender and net cash withdrawal values, for Minnesota residents covered by the plan provided, however, that the association shall not be responsible for more than $10,000,000 in claims from all Minnesota residents covered by the plan. If total claims exceed $10,000,000, the $10.000,000 shall be
prorated among all claimants. These are the maximum claim amounts.
Coverage by the guaranty association is also subject to other substantial limitations and exclusions and
requires continued residency in Minnesota. If your claim exceeds the guaranty association’s limits, you may still recover a part or all of that amount from the proceeds of the liquidation of the insolvent insurer, if any exist. Funds to pay claims may not be immediately available. The guaranty association assesses insurers
licensed to sell life and health insurance in Minnesota after the insolvency occurs. Claims are paid from
this assessment.
THE COVERAGE PROVIDED BY THE GUARANTY ASSOCIATION IS NOT A SUBSTITUTE FOR USING CARE IN SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND FINANCIALLY STABLE. IN SELECTING AN INSURANCE COMPANY OR POLICY, YOU SHOULD NOT RELY ON COVERAGE BY THE GUARANTY ASSOCIATION. THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDERS OF LIFE, ANNUITY, OR HEALTH INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR INSURANCE CARRIER BECOMES FINANCIALLY INSOLVENT. THIS NOTICE IN NO WAY IMPLIES THAT THE COMPANY CURRENTLY HAS ANY TYPE OF FINANCIAL PROBLEMS. ALL LIFE, ANNUITY, AND HEALTH INSURANCE POLICIES ARE REQUIRED TO PROVIDE THIS NOTICE.
L-15-32 (1/2010) MN
Grange Life Insurance Company 671 South High Street, P.O. Box 1218
PROPOSED INSURED
Name
p
Malep
FemaleAddress DOB Age
City State Zip Tax ID/SSN
Phone ( ) – Email
Are you a citizen of the United States?
p
Yesp
No If “No”, please provide a copy of your Permanent Resident Card.BENEFICIARY INFORMATION (person to be paid at death)
BENEFIT AMOUNT
p
$50,000p
$35,000p
$25,000p
$15,000p
Other $PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS (PROPOSED INSURED)
MEDICAL/HEALTH QUESTIONS
1. Have you been declined for Life Insurance in the past 12 months?
p
Yesp
No 2. Are you currently receiving hospice care; waiting on an organ or tissue transplant; or ever been diagnosed with a terminal illness; or tested positive for the HIV (Human Immunodeficiency Virus), or been diagnosed by a member of the medical profession as having ARC (AIDS Related Complex), or AIDS (Acquired Immune Deficiency Syndrome)?p
Yesp
NoFor Wisconsin Applicants Only: Test results of AIDS/HIV received at anonymous counseling and testing sites or results
received from a home test kit need not be disclosed.
STOP: If question 1 or 2 is answered “Yes”, the product is not available.
TOBACCO USE
3. Have you smoked one or more cigarettes in the past 12 months?
p
Yesp
NoINSURANCE INFORMATION
4. Will any Life Insurance or Annuities for this or any other company be replaced, discontinued, reduced or changed if
insurance now applied for is issued?
p
Yesp
No 5. Do you currently have any other Life Insurance or Annuities in force?p
Yesp
NoSTOP: If question 4 is answered “Yes”, the product is not available.
PAYMENT INFORMATION
I wish to be billed : (check one)
p
Monthly through Easy Pay (Please complete Easy Pay Authorization)p
Annuallyp
Other ______________ If monthly, I authorize Grange Life to draft my first monthly premium.If mode other than Easy Pay is selected, I am enclosing the first modal premium of $ _________________.
EASY PAY AUTHORIZATION
Monthly Amount: $ ___________ Routing Number: _____________ Account Number: _________________
Financial Institution: ____________________________________________
PLEASE ATTACH A COPY OF A VOIDED CHECK
By providing my Financial Institution name and account information, I hereby authorize Grange Life to initiate debit
entries to my checking/savings account indicated above and the Financial Institution to debit the same such account.
Grange Life will draft the first payment when the application is received in the Home Office. Subsequent monthly drafts will occur on the same day each month as the effective date unless otherwise requested.
Special Draft Date Request:_______________________
Special Instructions Section (If more space is needed, an additional blank sheet may be attached.)
Application for:
Graded Benefit Whole Life
L-3-54 (1/2010) MN
Beneficiary Name % Primary Contingent Relationship to Insured DOB SSN
p
p
p
p
p
p
Grange Life Insurance Company 671 South High Street, P.O. Box 1218
Columbus, Ohio 43216-1218 • (800) 399-3797
AUTHORIZATION
I represent that the statements and answers recorded on this application are true and complete and agree that they will form a part of any insurance policy issued hereon. I also understand that the information on this application will be relied upon to determine insurability and that incorrect information may result in coverage being voided, subject to the Incontestability Provision.
TEMPORARY INSURANCE
I agree that the insurance requested above will start upon the date of this application only if: (a) the first premium is paid; (b) questions 1, 2 and 4 are answered “No”; (c) the proposed insured is a citizen or permanent resident of the United States; and (d) the health of the proposed insured is as described above. Otherwise, the insurance will not take effect until a policy is issued by Grange Life and the first premium is paid. The initial premium will provide coverage from the policy issue date until the date the next premium is due. Should the application be declined,
the amount paid will be refunded. No agent can accept risks or make or change contracts or waive Grange Life’s rights or
requirements. All statements made are representations, not warranties. The entire contract will consist of the policy and this application. If the applicant is other than the proposed insured, the applicant will be the owner of this policy. The owner has the right to cancel this application at any time by contacting their agent or Grange Life in writing.
FRAUD NOTICE
WE ARE REQUIRED BY LAW TO GIVE YOU THE FOLLOWING NOTICE:
Ohio - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Kentucky - Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
IN ALL OTHER STATES, THE FOLLOWING NOTICE APPLIES:
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information may be subjected to criminal penalties and the denial of coverage for claims made under the policy of insurance.
SIGNATURE
Full Name of Proposed Insured (printed) _________________________________________________________________________
Signature of Proposed Insured _________________________________________________________________________________
Signed at (City, State) ____________________________________________________________ on _________________, 20______
AGENT’S REPORT
I certify that the information supplied by the proposed insured has been fully and accurately recorded on the application, and I have received the first full modal premium shown above or received all information for Easy Pay enrollment.
To the best of your knowledge does the applicant have any existing life or annuity policies?
p
Yesp
NoWill the insurance applied for replace any existing insurance?
p
Yesp
No Agent’s Name (printed):_______________________________ Agency Name: _______________________Agent’s Signature:____________________________________ Agent Number:_______________________
