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Document Preview Application for Life Insurance |
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Title: |
Application for Life Insurance |
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Entities: |
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Date: |
2000 |
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Size: |
Preview shows 22KB of 77KB total |
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Price: |
$52 |
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ID: |
#2759982 |
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Start of Preview |
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PEOPLES BENEFIT LIFE INSURANCE COMPANY
-----------------------------
HOME OFFICE:
4333 EDGEWOOD RD., N.E.
CEDAR RAPIDS, IA 52499
-----------------------------
-----------------------------
New Business
Conversion Policy #
---------
Rewrite Number
--------------
-----------------------------
APPLICATION FOR LIFE INSURANCE
Agent Name:
-----------------------------------------------------------------
Agent Number:
---------------------------------------------------------------
Broker/Dealer: (If Applicable)
----------------------------------------------
Date Faxed: (If Applicable)
-------------------------------------------------
Amount of initial premium with application $ | |,| | | |,| | | |.| | |
-------------------------
Amount to be applied with application
-----------------
$ | |,| | | |,| | | |.| | |
----------------- -------------------------
-----------------
$ | |,| | | |,| | | |.| | |
----------------- -------------------------
-----------------
$ | |,| | | |,| | | |.| | |
----------------- -------------------------
{TABLE}
{CAPTION}
DO: DON'T
--- -----
{S} {C}
[ ] Complete the entire application (front and back). [ ] Do not use pencil or whiteout.
[ ] Print application in black ink. [ ] Do not accept or send money on applications
that total more than $1,000,000.00
[ ] Have applicant initial all changes. [ ] Do not submit an agent check as the initial premium.
[ ] Obtain all required signatures. [ ] Do not submit starter checks or deposit slips for
checkomatic withdrawals.
[ ] Include certification if a trust is owner of the policy.
[ ] Attach additional sheet of paper if necessary.
{/TABLE}
6800 R1200
{PAGE} 2
{TABLE}
{CAPTION}
---------------------------
LIFE APPLICATION-PART 1 PBL - PEOPLES BENEFIT LIFE INSURANCE COMPANY APPLICATION #
---------------------------
{S} {C}
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SECTION 1. PROPOSED PRIMARY INSURED
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1. Last Name First Name M.I.
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2. Address Apt# City
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State Zip Code 3. Years at Address 4. Home Phone 5. Driver License Number State
( ) - -
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6. Sex 7. Date of Birth 8. Age 9. Place of Birth - State/County 10. Social Security Number
[ ] Male
[ ] Female
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11. Height 12. Weight 13. Marital Status 14. Employer Years
------------------------------------------------------------------------------------------------------------------------------------
15. Occupation & Duties
------------------------------------------------------------------------------------------------------------------------------------
16. Employer's Address 17. Business Phone Number
( ) - -
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18. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] No [ ] Yes, Date of last use
----------
------------------------------------------------------------------------------------------------------------------------------------
19. Rate Class Quoted: [ ] Super Preferred [ ] Preferred [ ] Preferred Tobacco [ ] Tobacco
[ ] Other
--------------------------------------------------------------------------------
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SECTION 2. PROPOSED ADDITIONAL/JOINT INSURED - IF MORE THAN ONE PLEASE USE A SUPPLEMENTAL APPLICATION
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1. Last Name First Name M.I.
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2. Address Apt# City
------------------------------------------------------------------------------------------------------------------------------------
State Zip Code 3. Years at Address 4. Home Phone 5. Driver License Number State
( ) - -
------------------------------------------------------------------------------------------------------------------------------------
6. Sex 7. Date of Birth 8. Age 9. Place of Birth - State/County 10. Social Security Number
[ ] Male
[ ] Female
------------------------------------------------------------------------------------------------------------------------------------
11. Height 12. Weight 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years
------------------------------------------------------------------------------------------------------------------------------------
16. Occupation & Duties
------------------------------------------------------------------------------------------------------------------------------------
17. Employer's Address 18. Business Phone Number
( ) - -
------------------------------------------------------------------------------------------------------------------------------------
19. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] No [ ] Yes Date of last use
----------
------------------------------------------------------------------------------------------------------------------------------------
20. Rate Class Quoted: [ ] Super Preferred [ ] Preferred [ ] Preferred Tobacco [ ] Tobacco
[ ] Other
--------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
SECTION 3. APPLICANT/OWNER IF OTHER THAN THE PROPOSED PRIMARY INSURED
------------------------------------------------------------------------------------------------------------------------------------
1. Last Name First Name M.I.
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2. Address Apt# City
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State Zip Code 3. Home Phone 4. Social Security Number/Tax ID #
( ) - -
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5. Date of Birth/Trust Date 6. Relationship to the Proposed Primary Insured
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SECTION 4. CHILDREN'S INSURANCE RIDER
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COVERAGE AMOUNT ($1,000 MINIMUM TO $25,000 MAXIMUM COVERAGE FOR CHILDREN 18 AND UNDER) $|_|_|,|_|_|_|
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Name Relationship Date of Birth Height Weight
------------------------------------------------------------------------------------------------------------------------------------
- - ft in lbs
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- - ft in lbs
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- - ft in lbs
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Are all children listed? [ ] Yes [ ] No Are children living with proposed primary insured? [ ] Yes [ ] No If not, explain why:____
------------------------------------------------------------------------------------------------------------------------------------
{/TABLE}
{PAGE} 3
LIFE APPLICATION
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SECTION 5. PRIMARY BENEFICIARY - IF PERCENTAGE SHARES ARE NOT GIVEN THEY WILL BE
EQUAL, OR TO the survivor
--------------------------------------------------------------------------------
{TABLE}
{S} {C} {C} {C}
Name Percent R&ationship Social Security Number/Tax lD#
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------
{/TABLE}
--------------------------------------------------------------------------------
SECTION 6. CONTINGENT 8ENEFICIARY - IF PERCENTAGE SHARES ARE NOT GIVEN THEY WILL
BE EQUAL, OR TO the survivor
--------------------------------------------------------------------------------
{TABLE}
{S} {C} {C} {C}
Name Percent R&ationship Social Security Number/Tax lD#
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------
{/TABLE}
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SECTION 7. PROPOSED PLAN OF INSURANCE:
------- ----------- ---------
--------------------------------------------------------------------------------
{TABLE}
{S} {C}
1. Variable Life__________________________________________________ 9. BenefitlRiders Benefit Units
2. No Lapse /Minimum Premium Period (if applicable) Monthly $ Amount
[ ]5 years [ ] 20 years [ ]30 years [ ]Age 100 [ ] Other [ ] Waiver of Premium Benefit (WP) _____________
3. Modal Premium $ ____________ [ ] Waiver of Monthly Deduction(WMD) _____________
[ ]Include rider(s) in stated premium [ ] Children's Rider (CBR) _____________
4. Face/Specified Amount $ ________________________________________ [ ] Additional Insured Rider (AIR) _____________
5. Excess: Modal Premium $_____________________________________ [ ] Base Insured Rider (BIR) _____________
Lump Sum Premium $__________________________________ [ ] Accidental Death Benefit (ADB) _____________
6. Total Initial Life Premium $ ____________________________________ [ ] Guaranteed Insurability Rider (GIR)_____________
7. Automatic Premium Loan (APL) [ ] Yes [ ] No [ ] Other_____________________________
Automatic Premium Payment Authorization (APPA) [ ] Yes [ ] No [ ] Other_____________________________
8. If Application is approved other than as requested:
[ ] Adjust premium [ ] Adjust face
{/TABLE}
--------------------------------------------------------------------------------
SECTION 8. DEATH BENEFIT OPTION:
--------------------------------------------------------------------------------
[ ] Level benefit [ ] Increasing benefit
--------------------------------------------------------------------------------
SECTION 9. PREMIUMS PAYABLE:
--------------------------------------------------------------------------------
{TABLE}
{CAPTION}
Planned Modal Premium: $ | | | |,| | | |. | | |
{S} {C} {C}
Billing Method: [ ] Checkomatic | | | Draft Date (1ST th Direct Bill ru 28TH)Complete Check-O-Matic authorization
[ ] Payroll Deduct [ ] Direct Bill [ ] Military Allot [ ] Civil Service Allot
Billing Frequency: [ ] Single Premium [ ] Semi-annual [ ] Monthly
[ ] Annual [ ] Quarterly [ ] Other________________________________________________
{/TABLE}
Billing Address: _______________________________________________________________
--------------------------------------------------------------------------------
SECTION 10: OTHER INSURANCE IN FORCE FOR ALL PROPOSED INSUREDS [ ] NONE
-----------------------------------
--------------------------------------------------------------------------------
{TABLE}
{CAPTION}
Proposed Insured 'Name Company Amount of insurance Year issued Replacement?
{S} {C} {C} {C} {C}
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| | | | | | | | | Yes No
---- ----
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| | | | | | | | | Yes No
---- ----
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| | | | | | | | | Yes No
---- ----
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| | | | | | | | | Yes No
---- ----
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{/TABLE}
{TABLE}
{S} {C} {C} {C}
IS THIS INTENDED TO BE A 1035 EXCHANGE? [ ] Yes [ ]No Anticipated Cash Value Transfer $ | | | |, | | |.| |
{/TABLE}
1. Will the insurance applied for on any proposed insured replace or change any
existing life or annuity policy? [ ]Yes [ ]No
IT YES, COMPLETE REPLACEMENT FORMS, IF APPROPRIATE.
2. To your knowledge, will the initial and/or future premiums come from
dividends, policy loans, withdrawals or cash surrender? If yes, provide
details below. [ ] Yes [ ] No
{TABLE}
{S} {C}
PBL Policy number ________________________ [ ] Non-PBL
Dividends $ _______________________________ Loan $ _________________________________
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