step 4: PAPERWORK
INSURED’S INFORMATION
Full Name:
Social Security #:
Sex:
Birthdate (M/D/YYYY):
Age:
Mailing Address:
City:
State:
Zip:
Telephone #:
CERTIFICATE INFORMATION
Total:
Face Amount $
Total Paid to Agent $
Total Paid to Agent $
Payment Method:
Single
BENEFICIARIES
Primary:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties.
ASSIGNMENT
|
Yes
No Initial Approval |
I hereby irrevocably assign and transfer all the benefits and proceeds of this certificate to as their interest may appear. I understand fully the effects of this assignment and transfer. It is my intention as owner to continue to pay premiums and retain ownership. |
Does the applicant have any existing policy or annuity?
No or Yes
No or Yes
Will the proposed insurance replace any existing policy or annuity?
No or Yes If yes, please complete a replacement form.
No or Yes If yes, please complete a replacement form.
INSURED’S NAME
AGREEMENT
By signing below, I agree that: (1) To the best of my knowledge and belief, statements in this Application are complete and true. (2) When the certificate is delivered, the Insured must be alive and in the same health as described above or there will be no insurance. Also, the full premium for the chosen period must be paid by the time the certificate is delivered. (3) By accepting the certificate, I approve any change(s), correction(s), or addition(s) that Great Western made when issuing it. If my approval requires written consent, a form will be included.
Insurable Interest: If the owner is other than the insured, by signing below, the owner certifies that he/she has insurable interest in the life of the insured as defined by the state statute in which the policy is issued.
Authorization: By signing below, I approve of any healthcare provider, medical facility, or other person, including a Veterans Administration Hospital, giving the Great Western Insurance Company any records or information it needs about the Insured’s health. A copy of this approval will be as effective as the original. This approval is only valid for 30 months. The Insured, or a person authorized to act on behalf of the Insured, is entitled to receive a copy of this authorization upon request. I affirm that no illustration was used in the sale of this product.
| Signed at , | Insured |
To the Applicant: You should hear from the Company within sixty days of the application date. If you don’t, state the facts of your application in a letter to the Secretary of Great Western Insurance Company at the address listed above.