MEDICARE SUPPLEMENT by benbenzhou

VIEWS: 15 PAGES: 8

									                                                                    PV Case #
Application for
Graded Benefit                      LOYAL AMERICAN LIFE INSURANCE COMPANY
Life Insurance &                                      P.O. Box 559015-Austin, TX 78755-9015
Final Expense
Life Insurance                            New Business                         Reinstatement                         Benefit Change

  1. Name of Proposed Insured (Print)                                                        Sex                  Birthdate                             Age                     Social Security No.
Last                              First                                     Initial                             (MM/DD/YY)                     Nearest Birthday

Street Address                                                City                                      State                Zip               Birth Place State                    Telephone No.
                                                                                                                                -
  2.                                      3. Premium $                                               Premium Payable:                     Annual    Semi-Annual Quarterly
                                                                                                                                          Monthly Bank Draft (BOM)
  Graded Benefit Life
Amount $
                                          Amount of Premium Submitted with the Application: $                                               (Check must be made payable to Loyal
  Final Expense Life                                                                                                                        American Insurance Company).
Amount $
                                          Requested Effective Date:                                                        Special Bill Date:

  4. Primary Beneficiary                                             Relationship                          Contingent Beneficiary                                           Relationship


 5. Owner, if other than the Proposed Insured                                                                                                                                   Social Security No.
Name:                           Relationship:                                            Address:

  6. Will the proposed insurance replace any existing policy or annuity?                                                  Yes             No
     If yes: Insurance Company Name and Address

  7. Telephone Verification of Your Application
        To assure that we have all the information needed to process your application, you will be contacted by telephone shortly after your agent
        submits your application. We will ask you a number of questions to be sure that all information on your application is complete and correct.
        Please indicate the best day/time to call you:
        Telephone Number:

  8. Tobacco Question. Have you used tobacco in any form within the last 2 years?                                                   Yes          No       9. Height                      Weight

 Medical Questions – When applying for either the Graded Benefit or Final Expense Life plan answer questions 10 – 14 below.                                                               Yes       No
 If any question is answered Yes, the Proposed Insured will not be eligible for either plan. (If applying for Final Expense Life,
 questions 15 – 22 must also be answered.)
 10. Are you now confined in a hospital, rest home, nursing home, assisted living facility, hospice or convalescent home? .........

 11. Are you now being treated for Cancer or any terminal illness which would, in the absence of medical intervention, result in
     a life expectancy of 24 months or less? ....................................................................................................................................

 12. Are you now being treated for Alzheimer’s Disease or Dementia, Renal or Kidney Failure, or any Respiratory Disease that
     requires the use of oxygen? .....................................................................................................................................................

 13. Have you ever had any organ transplant? ................................................................................................................................
 14. Have you ever been diagnosed or treated by a member of the medical profession as having or having had an immune
     disorder, Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or have you tested positive for
     the Human Immunodeficiency Virus on a test administered by a member of the medical profession? .....................................

 Final Expense Life Medical Questions – When applying for the Final Expense Life plan answer questions 15 – 22 below in
 addition to questions 10 – 14 above. If any of the following questions are answered Yes, the Proposed Insured will not be
 eligible for the Final Expense Life plan but may be eligible for the Graded Benefit plan.
 15. Have you ever been diagnosed with or treated for a terminal illness? .....................................................................................
 Final Expense Life Medical Questions continued on Page 2



L-5422-IL                                                                                      Page 1 of 4                                                                                        e-App
Final Expense Life Medical Questions (continued)                                                                                                                                                     Yes     No

16. Have you been hospitalized within the last 30 days or been hospitalized two or more times in the last two years or been
    confined to a nursing facility in the last two years? ...................................................................................................................
17. Within the past 2 years have you had, or been diagnosed as having:

       a) Angina, Heart Attack, Angioplasty, Cardiac or Vascular Stent, Cardiac Bypass Surgery, Heart Valve Surgery, or
          implantation of Cardiac Pacemaker or Defibrillator? ...........................................................................................................
       b) Stroke, MiniStroke, or Transient Ischemic Attack (TIA)? ....................................................................................................

       c) Internal Cancer or Melanoma? ...........................................................................................................................................

       d) Epilepsy or Epileptic Seizure? ............................................................................................................................................

18. Do you have now, or within the past 2 years, have you received medical advice, treatment, been advised to have
    treatment or surgery, or taken medication for:

       a) Cardiomyopathy or Congestive Heart Failure? ...................................................................................................................

       b) Cerebrovascular Blockage or Insufficiency, or Vascular Aneurysm? .................................................................................

       c) Leukemia, Hodgkin’s Disease or Lymphoma, or any other type of Cancer or Tumor not cured by surgery or treatment? .

       d) Chronic Lung Disease, Emphysema, or Chronic Obstructive Pulmonary Disease (COPD)? Or any type of other
          Chronic Pulmonary Disease that requires the use of oxygen? ...........................................................................................

       e) Chronic Kidney Disease, Renal Failure, Renal Insufficiency, Chronic Liver Disease, Hepatitis, Cirrhosis, Disease of the
          Pancreas? ...........................................................................................................................................................................

       f) Diabetes associated with Retinopathy, Neuropathy, or Amputation, or Insulin Dependent Diabetes? ...............................

       g) Parkinson’s Disease, Paralysis, Myasthenia Gravis, Multiple Sclerosis, Lupus or Connective Tissue Disorder, Muscular
          Dystrophy, Huntington’s Disease, or Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig’s Disease? ..............................

       h) Dementia, Senile Dementia, Alzheimer’s Disease, Organic Brain Disorder, Paranoia, Schizophrenia, or Major
          Depressive Disorder? ..........................................................................................................................................................
       i) Excessive use of Alcohol, Alcoholism, Drug Abuse, or Drug or Narcotic Addiction? ..........................................................

19. Within the last 5 years, have you ever been advised by a medical professional to have tests, surgery, treatment, or further
    medical evaluation that have not been performed, or do you have any medical test results pending? ....................................

20. Do you use a medical appliance such as a wheelchair, walker or hospital bed, or do you need assistance or supervision
    by another individual with dressing, eating, personal hygiene (bathing or toilet), walking, or transferring to or from a bed
    or chair? ....................................................................................................................................................................................

21. Within the last 90 days have you had undiagnosed chest pain, paralysis, fainting, bleeding moles, coughed or vomited
    blood, or passed blood through the bowels? ...........................................................................................................................
22. Within the past 1 year have you had any application for life insurance declined or postponed for any reason? ......................


Remarks:




L-5422-IL                                                                                           Page 2 of 4                                                                                            e-App
     I hereby apply to Loyal American Insurance Company, Austin, TX, for insurance to be issued upon the truth and completeness of the answers to
the above questions to the best of my knowledge, and agree that: (1) No agent has the authority to waive the answer to any question in the
application; (2) no insurance will be effective until the Premium for the Mode selected has been paid in full and the policy delivered; and (3) the
policy effective date will be the date this application is received by the company at the above address.
                                                                      AUTHORIZATION
    I hereby authorize any health care provider, including any physician, practitioner, pharmacy, prescription vendor, pharmacy benefit manager,
hospital or medically-related facility, and any insurance company, the Medical Insurance Bureau (MIB) or other consumer reporting agency,
employer, or, except in AZ, any other organization, institution or person that has my records or knowledge of me or my dependent(s) to disclose to
Loyal American Insurance Company (LALIC), or its authorized representative, any such records or information. Records or information may include
medical records in their entirety, which may contain mental health records (excluding psychotherapy notes), prescription drug records, use of
alcohol, or use of controlled or prohibited substances, driving records, financial and employment records. Such records or information will be used
by Company personnel to determine eligibility for insurance and/or benefits. LALIC may disclose such information to its reinsurer(s), precertification
firm, individual benefits management firms or any other organization which performs services in connection with the insurance relationship,
including, but not limited to, the insurance agent, or as lawfully required. However, LALIC shall not disclose to an agent information received from
MIB. LALIC reserves the right to require a medical examination or testing or both. There may be certain circumstances under which the information
received may be disclosed to third parties who are not subject to the regulations under federal health privacy law. We contractually require such
persons to agree to protect the confidentiality of the information. I understand that I have the right to request access to all personal information
collected and, upon written request, I may ask LALIC to correct, amend or delete any incorrect personal information. A copy of the Company’s
“Privacy Notice and Notice of Insurance Information Practices” is available upon request.
    This authorization shall be valid for a period of two (2) years from the date signed to determine eligibility for insurance. For determination of
benefits, the authorization shall be valid for either the term of coverage of the policy for health insurance products or for the duration of the claim for
all other insurance products. A photocopy of this authorization shall be as valid as the original. I understand that I, or my authorized representative
may receive a copy of this authorization upon request. This authorization may be revoked at any time subject to the rights of anyone who acted in
reliance upon the authorization prior to notice of its revocation. This authorization may be revoked upon submission of a written notice to the Home
Office. If this authorization was obtained as a condition of obtaining insurance coverage, your right to revoke also is subject to the rights of the
Company under any law granting the Company the right to contest a claim under the policy or the policy itself. Revocation or failure to sign the
authorization may be a basis for denying an application or eligibility for benefits.
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
 Dated at:         City                                                State                                         Date


Signature of Applicant:                                                                                         Date:


Signature of Owner ( if other than proposed insured):                                                           Date:


Signature of Authorized Representative:                             Relationship/                               Date:
                                                                    Authority to Represent:


Authorized Representative’s Address:


Authorized Representative’s Phone Number:
AGENT’S STATEMENT: Is insurance being applied for intended to replace any insurance now in force?                          Yes         No
I have truly and accurately recorded in this Application, the information supplied by applicant.
X
Signature of Licensed Agent                                                 Agent #

Agent’s Name (Please Print)
                                            INVESTIGATIVE CONSUMER REPORTS AUTHORIZATION
   As part of our normal procedure for processing your application, an investigative consumer report may be prepared whereby information is
obtained as to the character, general reputation, personal characteristics and mode of living of persons proposed for insurance in this application.
Personal interviews with friends, neighbors and associates may be used to develop this report. (In WV, no information collected concerning the
sexual orientation of the proposed insured will be used to determine his or her eligibility for insurance.) You may request to be interviewed in
connection with the preparation of the report. You have the right to request “A Summary of Your Rights Under the Fair Credit Reporting Act”.Upon
written request, you or your representatives have a right to receive a copy of the report and additional information about the nature and scope of the
investigation.
L-5422-IL                                                              Page 3 of 4                                                                e-App
                                           MEDICAL INFORMATION BUREAU (MIB) AUTHORIZATION
Information regarding your insurability will be treated as confidential. LALIC or our reinsurers may, however, make a brief report thereon to the
Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of
its members.

I understand that if I apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such
member company, the Bureau, upon request, will supply such member company with the information in its file.

By signing below, I authorize release of my information to MIB and MIB to any member company.


Signature of Applicant:                                                                                     Date:


Signature of Authorized Representative:                         Relationship/                               Date:
                                                                Authority to Represent


Authorized Representative’s Address:


Authorized Representative’s Phone Number:

                                                      ELECTRONIC APPLICATION
                                                    TAKEN IN PERSON   PHONE SALE



                                      NOTIFICATION REGARDING THE MEDICAL INFORMATION BUREAU
                                                   (To Be Left With The Proposed Insured)
Information regarding your insurability will be treated as confidential. LALIC or its reinsurers may, however, make a brief report thereon to the
Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of
its members. If you 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 in its file. Upon a receipt of a request from you, the Bureau will
arrange disclosure of any information it may have in your file. If you question the accuracy of the information in the Bureau’s file, you may contact
the Bureau and 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. LALIC or its reinsurers may also release
information in its file to its reinsurer(s) and to other life insurance companies to whom you may also apply for life or health insurance, or to whom a
claim for benefits may be submitted.




L-5422-IL                                                            Page 4 of 4                                                              e-App
                                                  P.O. Box 559015  Austin, Texas 78755-9015


      BANK AUTHORIZATION

           Checking                                    Savings                                          Special Bill Date (day of month)

    LOYAL AMERICAN LIFE INSURANCE COMPANY is hereby requested and authorized to draw checks to be charged against the
    checking or savings account of:

                                                        with
     (print name as shown on bank records)                     (name of bank and branch name, if any)



     (Bank Transit Number)                              (Bank Account Number)
    For the purpose of collecting premiums payable to LOYAL AMERICAN LIFE INSURANCE COMPANY under the bank check premium
    arrangement. The policy(ies) are to be placed under the bank check premium arrangement, upon approval by the Company, for
    premiums due. It is understood that LOYAL AMERICAN LIFE INSURANCE COMPANY’S premium arrangement may be terminated
    by the policy owner or by the Company upon written notice.

    As a convenience to me, I hereby request and authorize the bank named above to pay and charge my account debits drawn by Loyal
    American Life Insurance Company to its own order. This authorization will 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 debit. I agree that your treatment of
    each such check, and your rights in respect to it, shall be the same as if it were signed personally by me. I further agree that if any
    such check be dishonored, whether with or without cause, you shall be under no liability whatsoever even though such dishonor
    results in the forfeiture of insurance.


     (date)                             (signature of bank depositor/premium payor as shown on bank records for the
                                        account to which this authorization is applicable)

       INDEMNIFICATION AGREEMENT

    To: The Bank Named Above
    In consideration of your participation in a plan which the LOYAL AMERICAN LIFE INSURANCE COMPANY has put in effect by which
    amounts for premiums due on policies of insurance are collected by drafts drawn by the company on the accounts of persons who
    have made themselves responsible for these payments, the Company does hereby agree that subject to the terms and provisions of
    such insurance policies without varying, extending or altering the terms, thereof:

    (1) It will indemnify and hold you harmless from any liability to any person having an account with you arising out of the payment by
    you of any check drawn by the Company on the account of such person, or arising out of the dishonor by you, whether with or without
    cause or intentionally or inadvertently, of any such check drawn by the Company, whether or not such claim or liability asserted
    against you be based upon the forfeiture, or alleged forfeiture, of a policy of insurance the premium on which is sought to be collected
    by the Company by any such check; and

    (2) It will refund to you any amount erroneously paid by you on any such check if claim for the amount of such erroneous payment is
    made by you within a reasonable time from the date of the check on which such erroneous payment was made.




                                       ______________________________________________________



LOYAL-9-0007                                                                                                                               e-App
                                     Loyal American Life Insurance Company®
                                             P. O. Box 559015  Austin, Texas  78755-9015


                                             REPLACEMENT CERTIFICATION


Proposed Annuitant/Insured:

Owner(s)/Applicant(s):
(If not the Proposed Annuitant/Insured)

Hereinafter the Owner(s)/Applicant(s) shall be referred to as “Applicant”.


                                               EXISTING INSURANCE STATEMENT

     Do you, the Applicant, have existing individual life insurance policies or individual annuity contracts with this or any other company?

               NO         [If “No”, then the Agent and Applicant(s) must sign below and submit this form with the
                          application.]
               YES        [If “Yes”, then the Agent must complete the section “Agent Provided Sales Material Statement” below and
                          sign. Also, the Agent must present and read aloud to the Applicant(s) at the time of application (unless
                          reading is waived) the “Important Notice: Replacement of Life Insurance or Annuities”, form L-4349
                          (R7/00). Both this form and form L-4349 (R7/00) must be completed and signed by the Agent and Applicant
                          and submitted to Loyal American Life Insurance Company with the application.]




Applicant’s Signature and Printed Name                                                                                       Date


Agent’s Signature and Printed Name                                                                                           Date




                                   AGENT PROVIDED SALES MATERIAL STATEMENT
   (AGENT COMPLETES ONLY IF THE APPLICANT CHECKED “YES” ABOVE IN THE „EXISTING INSURANCE STATEMENT‟)

     I hereby certify that in connection with my presentation to the Applicant(s) herein, I only used sales material that were previously
     approved by Loyal American Life Insurance Company and that I left with or provided to the Applicant(s) a copy of all sales material
     used in my presentation with the Applicant.



Agent’s Signature and Printed Name                                                                                           Date




  L-5681 (7/00)                                                                                                                                e-App
                              Loyal American Life Insurance Company®
                                     P. O. Box 559015  Austin, Texas  78755-9015


                                          IMPORTANT NOTICE:
                                  Replacement of Life Insurance or Annuities
                     This document must be signed by the applicant and the producer, if there is one,
                                          and a copy left with the applicant.

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 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.

1.    Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or
      otherwise terminating your existing policy or contract? Yes      No

2.    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 contract or policy number if available) and
whether each contract or policy will be replaced or used as a source of financing:

Insurer Name                    Contract or Policy #            Insured or Annuitant         Replaced (R) or Financing (F)
1.
2.
3.

Make sure you know the facts. Contact your existing company or its agents 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

Agent's/Producer’s Signature and Agent's/Producer’s Printed Name           Date

I do not want this notice read aloud to me.         (Applicants must initial only if they do not want the notice read aloud.)


L-4349 (R7/00)                                                                                                         e-App
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?
   How does the quality and financial stability of the new company compare with your existing
   company.


L-4349 (R7/00)                                                                                  e-App

								
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