LPS APP – 2013 – PA – IN (Forms | Ladies Pennsylvania Slovak Catholic Union

LPS APP – 2013 – PA – IN

APPLICATION FOR LIFE INSURANCE – PART 1

Proposed Insured:(Required)

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Social Security Number

Gender

Male

Female

Age

Date Of Birth(Required)

Place Of Birth

Applicant Name (If other than Insured)

Relationship

Social Security Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Mail Premium Notice to:

Proposed Insured

Applicant

Plan of Insurance

Amount of Insurance

ADB

Riders

Waiver of Premium

Payor Death/Disability

Age of Payor

Beneficiary
(If more than one, then benefit paid equally to the survivors unless otherwise indicated. List additional beneficiaries in REMARKS)

Primary Beneficiary

Relationship to Insured

Contingent Beneficiary

Relationship to Insured

Will the insurance being applied for replace or change insurance in this or any other company? If Yes, give details and name of companies in REMARKS.

Yes

Dividend Option

Paid-Up Additions

Premium Reduction

Cash

Marital Status

Single, Widowed or Divorced

Married

Has the proposed insured ever been declined, postponed or rated up for life insurance?

Yes

Occupation of Insured or Applicant if insured is under 18 years of age

Name of Employer

Address

Street Address City State / Province / Region ZIP / Postal Code

Premiums are to be paid:

Annually

Semiannually

Quarterly

Monthly

Single Premium

Optional Secondary Addressee (for notification of a past due premium or possible lapse of coverage)

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

NOTE: 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.

Remarks

PART 2 - MEDICAL INFORMATION SECTION

If a medical examination is required, this page is to be filled out by the medical examiner; if application is non-medical, this page is to be filled out by the Proposed Insured (or the Applicant).

IN THE PAST 10 YEARS, HAS THE PROPOSED INSURED EVER HAD OR BEEN TREATED BY A LICENSED MEMBER OF THE MEDICAL PROFESSION FOR:

Disorder of eyes, ears, nose, mouth, throat or speech?

Yes

Dizziness, fainting, seizures or convulsions, chronic headache, epilepsy, paralysis or stroke or any disease of the brain or nervous system?

Yes

Chronic cough, asthma, emphysema, tuberculosis or any lung or respiratory disorder?

Yes

Chest pain, high blood pressure, heart attack, or any disorder of the heart or blood vessels?

Yes

Hepatitis, intestinal bleeding, ulcer, colitis, diverticulitis, or any disorder or disease of the stomach, intestines or bowel, rectum, appendix, liver or gall bladder?

Yes

Sugar, albumin, blood or pus in urine, venereal disease, stone or any other disorder of the kidney, bladder, prostate or reproductive organs?

Yes

Diabetes, thyroid or other glandular disorder?

Yes

Sciatica, arthritis, gout, or disorder of the muscles, bones, joints, spine, back or neck?

Yes

Cancer, tumor or disorder of the lymph glands or breasts?

Yes

Allergies, anemia or other disorder of the blood?

Yes

Alcoholism or drug abuse?

Yes

OTHER THAN AS LISTED ABOVE, HAS THE PROPOSED INSURED, WITHIN THE LAST 5 YEARS:

Had any mental or physical disorder?

Yes

Had an illness, injury or surgery?

Yes

Been a patient in a hospital, clinic, sanatorium or other medical facility?

Yes

Been scheduled to have any test, consultation, hospitalization or surgery which was not completed (other than for AIDS or AIDS-related condition)?

Yes

Is the Proposed Insured taking any medication or drugs (legal or illegal, prescription or non-prescription) for any reason?

Yes

Has the Proposed Insured ever been diagnosed by a licensed physician as having or been treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related-Complex (ARC), Human Immunodeficiency Virus (HIV) or any other disease of the immune system?

Yes

Does the Proposed Insured have a family history of diabetes, cancer, melanoma, heart or kidney disease, mental illness or suicide, or any hereditary disease?

Yes

Has the Proposed Insured used tobacco or nicotine in any form in the last 12 months?

Yes

What is the Proposed Insured’s height?

What is the Proposed Insured’s weight?

If any of the above questions have been answered YES, give particulars:

MEDICAL EXAMINER’S STATEMENT
I have completed the questions in Part 2 and the answers are true, complete and correctly recorded to the best of my knowledge and belief.

This signature will be requested directly by LPSCU after the form is submitted.

PROPOSED INSURED/APPLICANT STATEMENT

I declare that the statements and answers given in Part 1 and Part 2 are true, complete and correctly recorded to the best of my knowledge and belief. I understand that coverage will not be effective until the first premium has been paid and the contract has been delivered.

I authorize the LADIES PENNSYLVANIA SLOVAK CATHOLIC UNION, its agents, employees, reinsurers, and their representatives to obtain information about the Proposed Insured to evaluate this application and to verify information in this application. This information will include: (a) age; (b) medical history, condition and care; (c) physical and mental health; (d) occupation; and (e) other insurance. This authorization extends to information on the use of alcohol, drugs and tobacco; the diagnosis or treatment of HIV (AIDS virus) infection and sexually transmitted diseases; and the diagnosis and treatment of mental illness. During the time this authorization is valid it extends to information required to determine eligibility for benefits under any policy issued as a result of this application.

I authorize any person, including any physician, health care professional, hospital, clinic, medical facility, government agency including the Veterans and Social Security Administrations, employer, consumer reporting agency, or other insurance company, to release information about the Proposed Insured to the LADIES PENNSYLVANIA SLOVAK CATHOLIC UNION or its representatives on receipt of this authorization. This information should include medical history, physical and laboratory findings (special tests, X-rays, electrocardiograms, etc.) and conclusions regarding the Proposed Insured’s health. The information will be used to determine whether or not the Proposed Insured is an acceptable risk for life insurance. The LADIES PENNSYLVANIA SLOVAK CATHOLIC UNION or its representatives may release this information about the Proposed Insured to reinsurers or to another insurance company to whom the Proposed Insured has applied or to whom a claim has been made. No other release may be made except as allowed by law or as I further authorize.

This authorization is valid for 60 days from the date it is signed. A copy of this authorization is as valid as the original and will be provided on request. I may revoke this authorization at any time by writing to the LADIES PENNSYLVANIA SLOVAK CATHOLIC UNION.

Signature of Proposed Insured/Applicant Date Signed by Proposed Insured/Applicant

Signature of Adult Applicant if Proposed Date Signed by Adult Applicant Insured is under the age of 18

Signature of Member Applicant if Proposed Date Signed by Member Applicant Insured is not a member of the Society

RECOMMENDER’S STATEMENT

Was this insurance applied for to replace or change any existing insurance or annuity contract? If Yes, provide required disclosure notices to the Proposed Insured/Applicant.

Yes

This signature will be requested directly by LPSCU after the form is submitted

CAPTCHA