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Microsoft word - app - nwla 7-09.docTexas Life Insurance Company
Level Death Benefit
100 Centerview, Suite 100 Nashville, Tennessee 37214 DESCRIPTION OF INFORMATION PRACTICES
To Our Policyholders, Applicants and Insured’s: This description of the Information Practices of Texas Life Insurance Company and your agent is being provided in accordance with the requirement of the Insurance Information and Privacy Protection Law in effect in your state of residence. In order to properly underwrite and administer your insurance coverage we must collect a certain amount of information.
You are our most important source of information, but we may also collect or verify information by contacting other
sources, such as medical professionals, which have provided care to you or members of your family proposed for
coverage. In some circumstances we may disclose personal information to third parties without your specific
authorization. You have the right to be told about and obtain access to certain items of personal information in our files.
You also have the right to request correction of information you believe to be inaccurate. If you would like to receive a
more detailed description of our information practices, please write us at our Administrative Office: 100 Centerview, Suite
100, Nashville, Tennessee 37214.
PRE-NOTIFICATION - PUBLIC LAW 91-508 – FAIR CREDIT REPORTING ACT
This is to inform you that as a part of the Company’s underwriting procedure for processing applications for insurance, an
investigative report by a consumer reporting agency may be made concerning you and any person requesting insurance
whereby information is obtained from personal interviews with neighbors, friends, associates or others acquainted with
you, and those to be insured, as to character, general reputation, personal characteristics and mode of living. You have
the right to make a written request within a reasonable period of time to receive additional detailed information about the
nature and scope of this investigation. This written request should be directed to the Company at 100 Centerview, Suite
100, Nashville, Tennessee 37214.
If you elect to pay the Initial Advanced Premium with a bank draft
• You must attach a VOID check or the document indicated below. • If the appropriate documentation is not attached, the application will be held until the required document is • Checking Accounts – attach blank VOID check only, deposit slip not acceptable
• Savings Accounts – Attach a dep
osit slip or the top portion of your bank statement showing the account information or complete a Bank Account Verification Form. • Debit Card user – Complete a Bank Account Verification Form. (To draft your account we must
• Credit Cards – Master Card and Visa only - Complete a Credit Card Authorization Form.
• Draft for Electronic Check –
Attach the “Echeck” form and follow directions on the form. Remember to post the Initial Advanced Premium to your check register.
NOTICE CONCERNING THE MEDICAL INFORMATION BUREAU
Information regarding your insurability will be treated as confidential. Texas Life Insurance Company, or its reinsurers may, however, make a brief report thereon to MIB, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its Members. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with information in its file. Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901 (TTY 866-346-3642). If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting act. The address of MIB’s information office is Post Office Box 105, Essex Station, Boston, Massachusetts 02112. Texas Life Insurance Company or its reinsurers, may also release information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Receipt of Advanced Premium
The following should be completed if an application is taken and the initial advanced premium is given to the agent. Received from _________________________________the sum of $______________________as an initial advanced premium on an Insurance Application on the life of ______________________________________. No coverage will be in effect until the effective date of the policy and the first premium has been collected during the
lifetime of the insured. If for any reason the application is not approved, this payment will be refunded in full.
If the first premium is paid by bank draft the applicant must check the appropriate box on the application, and submit a
bank draft authorization. The bank draft authorization must contain the signature of an authorized person for the account.
You must attach a VOID check, or complete the Bank Account Verification form
Date _______________ Agent’s Signature ______________________________________
The Company accepts payment by check, draft, or money order subject to its being collected and/or honored by your
financial institution. No coverage will be effective if the financial institution does not honor the initial advanced premium.
Checks, drafts, or money orders must be made payable to Texas Life Insurance Company. Do NOT leave payee blank or
make payable to the agent.
Remember to post the Initial Advanced Premium to your check register.
TEXAS LIFE INSURANCE COMPANY
Application for Individual Whole Life Insurance
Level Death Benefit NWLA 7/09
SECTION 1 - APPLICATION FOR INSURANCE
First Name MI Last Name (indicate if hyphenated name) State of Birth
Automatic Premium Loan will be provided. Social Security No. No Check if APL is NOT desired. Do you have any existing life insurance or annuity contracts in force? Underwriting Class
Will the proposed insurance replace any existing life insurance or annuity? If Yes, give name of Company and face amount: ________________________________________________ In the past year, have you had any life insurance contract declined, postponed, or rated? Requested Effective Date (if other than issue date) BILLING MODES: A S/A Q M (EFT)
PAY FIRST PREMIUM BY: Check Draft Credit Card
SECTION 2 - BENEFICIARY DESIGNATION
SECTION 3 - OWNER FOR POLICY IF OTHER THAN PROPOSED INSURED
First Name MI Last Name (indicate if hyphenated)
SECTION 4 - IF ANY OF THE FOLLOWING QUESTIONS ARE ANSWERED “YES”, LEVEL COVERAGE CAN NOT BE ISSUED
1) Have you ever been diagnosed or treated by a medical professional for: Acquired Immune Deficiency Syndrome (AIDS), AIDS
Related Complex (ARC) or tested positive for Human Immunodeficiency Virus (HIV)? Yes No 2) Are you now, or have you been in the past 90 days: confined to a Hospital, Psychiatric or Nursing Facility, receiving Home Health
Care or need personal assistance performing activities of daily living such as bathing, dressing, eating, toileting, moving about or 3) Have you ever been medically diagnosed as having, been treated for, or been prescribed or taken medication for:
a) life expectancy of 12 months or less; any end stage disease or condition? b) Parkinson’s Disease; Sickle Cell Anemia; Alzheimer’s Disease or Dementia; or have you been prescribed any of the following medications: Aricept, Reminyl, Razadyne, Cognex, Namenda, and Exelon? c) Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Cirrhosis, Systemic Lupus (SLE), Congestive Heart Failure (CHF), 4) Have you ever received or been advised you needed to receive: an Organ or Tissue Transplant? Yes No
5) Have you been advised or recommended to have any diagnostic testing, surgery, Home Health Care, or hospitalization
which has not been completed or for which the results have not been received, or been advised to take any medication and
have not been compliant?
6) Currently, or in the past 2 years have you had, been medically diagnosed, treated, taken or been prescribed medication for:
a) Kidney Disease, Dialysis, Renal Insufficiency or Renal Failure; Chronic Hepatitis, Hepatitis C; or Liver Disease? b) Tuberculosis, Black Lung, Cystic Fibrosis, or other Chronic Respiratory Disorders (excluding Asthma), or used oxygen equipment to assist in breathing (excluding CPAP or Nebulizer)? c) Alcohol Abuse, Drug Abuse, used Illegal Substances, or been confined to a Correctional Facility? 7) Currently, or in the past 2 years have you had, been medically diagnosed, treated, taken or been prescribed medication for:
Brain Tumor, Internal Cancer, Leukemia or Melanoma (excluding Basal/Squamous cell skin cancer)? 8) In the past 2 years have you:
a) Had an occurrence of or been diagnosed for: Stroke; Transient Ischemic Attack (TIA); Aneurysm; Heart Attack; or
b) Had Brain, Heart or Circulatory surgery, Bypass surgery, Angioplasty, Stent insertion, or any procedure to improve circulation, such
as Femoral bypass (lower extremities) or Endarectomy (carotid arteries)? 9) In the past 2 years, have you experienced complications of diabetes (Type 1 or Type 2) such as:
a) Neuropathy, Amputation, or Retinopathy; Diabetic Coma, Insulin Shock or Diabetic Shock?; or are you b) Taking Insulin for Diabetes combined with medications for any Heart or Circulatory disorder (excluding medications for Blood Texas Life Insurance Company, Administrative Office, 100 Centerview Drive, Suite 100, Nashville, TN 37214 MEDICAL AUTHORIZATION: I, THE PROPOSED INSURED, AUTHORIZE any physician, medical practitioner, hospital, clinic, pharmacy benefit
manager, other medical or medically related facility, insurance or reinsuring company, the Medical Information Bureau, Inc.(“MIB”), consumer reporting agency, employer, relative, friend or neighbor to give to Texas Life Insurance Company or its reinsurer(s) all information it holds that pertains to medical consultations, treatments, surgeries, prescription drug records, and hospital confinements which relate to the physical and mental condition of myself. This Authorization also includes information about drugs or alcoholism or any other medical history information. I understand that such information will be used to determine eligibility for insurance, or for benefits under existing insurance. I further authorize Texas Life Insurance Company to release any information obtained only to reinsuring companies, MIB, or other persons or Organizations performing business or legal services in connection with my application or claim, or as may be otherwise lawfully required or as I may further authorize. As to this Authorization, I agree that a photographic copy will be as valid as the original and that it will be valid for 24 months from the date the Authorization is signed and may be revoked by sending written notice to Texas Life Insurance Company. I know that I, or my representative may request a copy of this Authorization.
APPLICANT’S STATEMENT: I have read the completed Application. The above representations are true to the best of my knowledge and belief. I
agree the policy shall not be in effect until the initial premium has been paid in full and the policy has been issued by Texas Life Insurance Company during the lifetime of the Proposed Insured. I understand that the information on this Application will be relied upon to determine insurability and underwriting class, and that incorrect information may result in coverage being contested, subject to the policy Incontestability Provision. I understand that the agent has no authority to change or approve the Application, change the policy, waive any policy provisions or has no authority to approve a claim. I understand no insurance will be effective until the date stated in the policy and the initial premium has been collected and/or honored by your financial institution.
Any person who knowingly and with intent to defraud any insurance company submits an application for insurance or statement of claim
containing any materially false information, or conceals information concerning any fact material thereto for the purpose of misleading may
be committing a crime which may subject such person to criminal and civil penalties.
For Residents in Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
I Acknowledge receipt of the following notices and disclosures:
(a) “Description of Information Practices” required by Public Law 91-508 and other information practices statutes, (b) Pre Notification - Fair Credit Reporting Act, and (c) Notice Concerning the Medical Information Bureau. I have paid the sum of $____________ with this Application, dated at _________________________________________________________ this __________ day of _____________________ 20______. X___________________________________________ X ___________________________________________ Signature of Owner (if other than Proposed Insured)
AGENT’S STATEMENT: I did not observe and I am not aware of any other information that might affect the insurability or underwriting class of the
proposed insured. I certify that any information recorded by me on this application is true and accurate to the best of my knowledge. I further certify that I have interviewed the applicant face to face, and witnessed the applicant’s signature. In addition, To the best of my knowledge the applicant does does not have existing life insurance policies or annuity contracts and the insurance applied for will will not replace
________________________________________________________ Administrative Use: Licensed Agent’s Signature State License No. ________________________________________________________ IF MONTHLY BANK DRAFT - ATTACH VOIDED CHECK AND SIGN AUTHORIZATION
As a convenience to me, I hereby request and authorize you to initiate debit entries, whether by electronic or paper means, with these debits made to my account and drawn by Texas Life Insurance Company, Nashville, Tennessee provided there are sufficient collected funds in that account to pay the same upon presentation. I agree that your rights in respect to such debit shall be the same as if they were a check drawn on you and signed personally by me. I hereby agree that if any debit is not paid by me for any reason with or without cause or whether such nonpayment is intentional, inadvertent or otherwise, you shall be under no liability whatsoever, even though such nonpayment results in the forfeiture of insurance. This authorization is to remain in full force and effect until revoked by me upon 30 days advance written notice, and until you actually receive such notice, I agree that you shall be fully protected in honoring any such debit to my account. Transit / Routing #
Draft Start Date
Printed name, as it appears on bank records Signature, as it appears on bank records Date
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