All premiums will be applied toward the insurance for which you qualify.
If the Face Amount shown above is $10,000 or greater and the product issued is the Express Issue Whole Life, the following riders will be attached to the policy:
If “Yes,” please complete any necessary replacement forms.
If the plan selected in Section 4 is the Graded Death Benefit Endowment, the Proposed Insured should not answer the health questions below.
If any question in Part A is answered “Yes”, you are not eligible for Express Issue Whole Life.
D) In the past twelve (12) months:
If any question in Part B is answered “Yes”, you are not eligible for Express Issue Deluxe. Submit the case as Express Issue Whole Life.
A) In the past 2 years:
1. Have you been diagnosed or treated for, or are you currently under treatment for:
If any question in Part C is answered “Yes”, you are not eligible for Express Issue Premier. Submit the case as Express Issue Deluxe.
If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (including the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing:
Insured Or Annuitant Replaced (R) Or Financing (F)
The existing policy or contract is being replaced because
I hereby apply for the insurance indicated above and i am submitting the first premimum. i have read (or have had read to me) all statements and answers recorded on this application and i certify that the answere are true and accurate whether by me own hand or not. i understand that my policy will not be effective untill the later of the date is issued bye the company as applied for and the premimium paid or the date of my written acceptance of the policy is issued other than applied for the premium paid.
I declare that i have read and receiver a copy of the Fair Oredit Reporting Act/MB, Inc , Notice
Any person who with intent to defaud or knowing that he is facilitating a froud against an insurer submits an application or files a claim containing a false or deceprive srarement may be gioltu of insurance fraud which is a crime.
i here by certify under penalties of perjury that the tax identificaion number ptovided is true correct and complete.
I hereby authorize any licensed physician medical praditioner hospital dinic or other medical or medicalu related facility insurance company or MB, Inc (MB). or other organization, insitition or person that has any records or knowledge of me dependenrs if they are to be insured or our health to give the United Home Life Insurance Company (UHL) or its reinsurer(s) any sach information . UHL may also sach information to reinsurers MB person or entities performing bussiness professional or insurance functions for UHL or as may otherwise be legally allowed . I furthrt authorize UHL or its reinsurer to male a brief report of my personal health information to MB i understand that i am giving permission to release medical information which may indude treatment og physical and or emotional diseases alchol or druh abuse treatment and or HV AIDS or AIDS related indormation.
I understand that UHL may require that i submit to an HV (HTL VLL ) screen i authorize that test for underwriting purposes.
A photographic copy of this authorization shall be as valid as the orignal . this release may be used for any legitimeate unsurance pyrpose for up to two (2) years from the dare of my signature below , I have a right to recive a copy of this authorization.
I authorize any health plan physician health care professional hospital clinic laboratory pharmacy or pharmacy benefit manager medical facility or other health care provider that has provided payment trearment or serviced to me or on my behalf within the past 10 years (my providers ) to disdose my enrire medical record prescription history medicarions prescribed and any other protectrf health information concerning me to united home life insurance company and its agents employee and representatives . united home life insirance company may disdose sach information to reinsurers MB persons or enities perfominh business professional or insurance functio for united home life insurance company or as may otherwise be legallu allowed . this includes information on the diagnosis or treatmet of human immunaodeficiency virus (HV) infection and sexually transmitted diseases . this also includes information on the diagnosis and treatment of mental illness and the use of alcohol drugs and tobacoo but exdudes psychotherapy notes.
By my signature below, i acknowledge that any agreements i have made to restricts my protected health information do not apply to this authorizarion and i instruct any physician health care professional hospital clinic medical facilitu or ther health care provider to release and disclise my entire medical recoed without restiction.
This prorected health information is to be disdosed under this authorization so that united home life insurance company may u underwrite my applicatuion for coverage make eligibility risl rating policy issuance and endlment determinations 2) dotain reinsurance 3) administer daim and determine or fullfill resonsibility for coverage and provision of benefirs 4) administer coverage and 5) conduct other legaly permissible activities tht relate to any or applied for with united home life insurance company.
This authorization shall remain in force for 24 months following the date of my signature below and a copy image or facsimile of this authhorization is as valid as the origna . i understand that i have the right to the revoke this autorizationn in hte writing at any time by providing written request to. united home life insurance company at p.o. box 7192 indiaapolis In 46207-7192 Attention Director life underwriting . i understand that a revocation is not effect to the extent that any of my providers has already relied on this authorization to disclose information about me or to the extant that united home life insurance company has a legal right to contest a claim under an insurance policy or to contest the policy itself. i understand that any information that is desclosed pursuant to this authorization may be re discloased and no longer coverd by federal rules giverning privacy and confidentality of health information.
I understand that my providers may not refuse to provide treatment or payment for health care services of i refuse to sign this authorization . i further understand if i refuse to sign this authorization to rekease my complete medical record . united home life insurance company may not be able to process my application, or if coverage has been issued may not be able to make any benefit payment. i have a right to receive a copy of this authoriztion.
I acknowledge receipt of the terminal illness accelereated benefir Disclosure statment with a numerical illustration showing the effect of the accelerated benefit on the policy face amount _this benefit is not available with the modified Death benefit Whole life plan.)
B.If under age 65, are you currently disabled, or been disabled in the last six months or at any time during the last six months received any disability compensation or been mentally or physically unable to complete 30 hours per week of active employment?