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RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY
0000 XXXXXXXX XXXX, XXXXXXXX, XXX XXXX 00000
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APPLICATION FOR LIFE INSURANCE
DIRECTIONS
The Agent is responsible for completing the necessary forms required to process
and underwrite this application. All forms must be completed in full and must be
legible. The directions below should be followed carefully.
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DO DON'T
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Submit separate applications on each person to Don't send money on applications totaling over
be insured. (Except when applying for spouse, $1,000,000 ($25,000 for proposed insured(s) under
children or other insured with amount of age 15) including any ADB amount (remember to
insurance below $100,000, use Part III ). include all pending and in force (with ADB) with
RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY,
Print application in black ink, if possible. Bankers Security Life Insurance Society or The
Get all required signatures. North Atlantic Life Insurance Company of America
All corrections must be initialed by the proposed in your calculation).
insured. Put one line through the incorrect answer and
insert the correct information. DO NOT USE WHITEOUT. Don't type or use pencil.
Complete and sign the Agent's Report, especially Don't forget to tell your client to fast a minimum
Question 5. Review the appropriate state replacement of 4 hours before any underwriting testing (Exam, HOS,
regulation for the definition of 'Replacement.' EKG and Blood Profile).
Complete Part II if Proposed insured is to be
considered for non-medical coverage.
Refer to Company Beneficiary Brochure for sample
wording.
Complete a Financial Supplement, if the application
is for more than: $ 300,000 - up to age 60
$ 250,000 - over age 60
Submit appropriate form and premium(s) for
Check-0-Matic (COM).
Give the Notification below to the applicant
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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY
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NOTICE AS REQUIRED BY THE FAIR CREDIT REPORTING ACT
ABBREVIATED NOTICE REGARDING INSURANCE INFORMATION PRACTICES
A consumer report about you and any other person proposed for insurance may be
made; this is in connection with and is a normal part of our processing of your
application. The people making the report will talk to your friends, neighbors,
family members, co-workers and others having knowledge of you; they will ask
about your business and personal life. You have a right to ask us in writing
whether such a report was prepared; we must give you the name and address of the
Agency which made the report, if any. The Agency will give you a copy of the
report if you ask them for it. All information collected by us either from you
or other sources may in certain circumstances be disclosed to third parties
without authorization more specific than as set forth in this application. You
have a right of access and correction with respect to the data, except that
which relates to a claim or civil or criminal proceeding or to medical record
information. Medical record information may be accessed by a medical
professional you designate. Our Underwriting Department will provide a more
detailed review of our information practices if you request it.
(PLEASE SEE REVERSE SIDE FOR IMPORTANT NOTICE)
FCRA/93
NOTICE REGARDING MEDICAL INFORMATION BUREAU
PLEASE READ CAREFULLY
Information regarding your insurability will be treated as confidential.
RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY, or its reinsurers may,
however, make a brief report thereon to the Medical Information Bureau, a
non-profit membership organization of life insurance companies, which operates
an information exchange on behalf of its members. If you apply to another Bureau
member company for life or health insurance coverage, or a claim for benefits is
submitted to such a company, the Bureau, upon request, will supply. such company
with the information in its file.
RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY, or its reinsurers, may also
release information in its file to other life insurance companies to whom you
may apply for life or health insurance, or to whom a claim for life benefits may
be submitted.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the Bureau's file, you may contact the Bureau and seek a
correction in accordance with the procedures set forth in the Federal Fair
Credit Reporting Act. The address of the Bureau's information office is Post
Xxxxxx Xxx 000 Xxxxx Xxxxxxx, Xxxxxx, Xxxxxxxxxxxxx 00000, telephone number
(000) 000-0000.
(PLEASE SEE REVERSE SIDE FOR IMPORTANT NOTICE)
MIB/93
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RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY
0000 XXXXXXXX XXXX, XXXXXXXX, XXX XXXX 00000
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CONDITIONAL PREMIUM RECEIPT
(Not Valid Unless Signed by Agent and Applicant)
THIS CONDITIONAL PREMIUM RECEIPT DOES NOT PROVIDE TEMPORARY OR IMMEDIATE
INSURANCE COVERAGE, IT IS HEREBY UNDERSTOOD AND AGREED THAT UNLESS EACH AND
EVERY CONDITION SPECIFIED IN PARAGRAPH "FIRST' IS FULFILLED EXACTLY, NO
INSURANCE WILL BECOME EFFECTIVE PRIOR TO POLICY DELIVERY. NEITHER THE AGENT
WHOSE SIGNATURE APPEARS BELOW, NOR ANY OTHER AGENT OF THE COMPANY OR BROKER IS
AUTHORIZED TO ALTER OR WAIVE ANY OF SUCH CONDITIONS.
Received from ______________________________________________ (Payor) the sum of
$________________________________________ as premium deposit which is tendered,
subject to the conditions of this Conditional Premium Receipt, as payment toward
the first premium of the life insurance policy applied for in the written
application to RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY, bearing the
same date and number as this Conditional Premium Receipt.
FIRST. CONDITIONS UNDER WHICH INSURANCE MAY BECOME EFFECTIVE PRIOR TO POLICY
DELIVERY. IF EACH AND EVERY ONE OF THE FOLLOWING CONDITIONS SHALL HAVE BEEN
FULFILLED EXACTLY:
(a) the amount of money taken with the application is at least equal to
1/12 of an annual premium for the amount and plan of insurance
applied for and is $20 or more;
(b) the completion of all parts of the initial application;
(c) the first and second medical examination, (if required by the Company's
published rules for the age of the person and amount of insurance applied
for) must be completed, within 60 days from the date of the application;
(d) completion of all investigations required by the Company;
(e) On the Effective Date, as defined below, all persons proposed for insurance
as named in this application were risks acceptable for insurance exactly as
applied for under the Company's rules, limits and standards, without
modification for the Plan and amount of insurance.
then insurance, as provided by the terms and conditions of the policy applied
for and in use by the Company on the Effective Date, but for an amount not
exceeding that specified in paragraph "SECOND", will become effective as of the
Effective Date.
Date: ____________________________________________________
DO NOT DETACH THIS CONDITIONAL PREMIUM RECEIPT UNLESS A PREMIUM DEPOSIT IS MADE
AT THE TIME OF APPLICATION.
"Effective Date", as used herein, means the latest of: (a) the date of the
application, or lb) the date of the first medical examination, (or if required
by the Company ' s published rules for the age of the person and amount of
insurance applied for, the second medical examination).
SECOND. LIMITS PROVISION: MAXIMUM AMOUNT OF INSURANCE WHICH MAY BECOME
EFFECTIVE PRIOR TO POLICY DELIVERY.
The total amount of insurance which may become effective on the life of each
person proposed for insurance prior to policy delivery is limited to the lesser
of: (a) $1,000,000, ($25,000 for proposed insureds under age 15), reduced by any
life insurance (life insurance plus Accidental Death Benefit) on the life of the
individual currently pending issue or additionally applied for with the Company,
or (b) the amount applied for under this application.
THIRD. RETURN OF PREMIUM DEPOSIT TAKEN.
If one or more of the conditions in paragraph "FIRST' have not been fulfilled
exactly, this Conditional Premium Receipt shall be considered null and void and
there shall be no liability on the part of the Company except to return the
Premium Deposit. Any delay in the Return of the Premium Deposit will not be
construed as approval of the application.
Agent:___________________________________________________
I ACKNOWLEDGE THAT I HAVE READ THE CONDITIONAL PREMIUM RECEIPT AND THE AGREEMENT
IN THE APPLICATION. THE TERMS, CONDITIONS AND LIMITS PROVISION, TO WHICH I
AGREE, AND THE AGREEMENT IN THE APPLICATION HAVE BEEN EXPLAINED TO ME FULLY BY
THE AGENT AND I UNDERSTAND THEM.
Applicant:________________________________________________
CR-93
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APPLICATION FOR RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY
LIFE INSURANCE 0000 Xxxxxxxx Xxxx, Xxxxxxxx, Xxx Xxxx 00000
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PART I
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1 a. Name of Proposed / / Male / / Female b. Are you known, or have you ever been known by
First Middle Last any other name? / / Yes / / No
List name(s):
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x. Xxxx of Birth d. Birthplace e. Social Security No.: f. Are you a citizen of the
Month Day Year (state/country) U.S.?
__ __ __ - __ __ - __ __ __ / / Yes / / No
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g. / / Single / / Married / / Divorced / / Widowed / / Separated
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h. Residence (Street, City, State, Zip) How Long i. Former Residence (within 5 years) How Long
Phone #( )
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j. Employer's Name and Address
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k. Occupation Describe Duties How Long l. Send premium notice to:
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2 a. Name and Address of Policy Owner b. Relationship to Proposed c. Soc. Sec. No. or
(if other than Proposed Insured) Insured: Tax. I.D. No.:
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d. Owner is: / / Individual / / Partnership
/ / Corporation / / Trustee
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3 a. Face Amount of Basic Policy b. Policy Plan c. Death Benefit Option (if applicable)
/ / Option A - level
/ / Option B - additional/increasing
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d. Have you used tobacco in any form in the past 12 e. If "No," check whichever is appropriate:
months? / / Yes / / No / / Never used / / Quit - give month and year
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4 COMPLETE FOR UNIVERSAL LIFE ONLY
a. First year planned periodic b. Subsequent planned periodic c. Other Insured Rider (OIR) / / Yes
premium based on Mode premium based on Mode Name:
$ $ Amount: $
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5 a. Premiums Payable: b. Additional Benefits (check if desired)
/ / Annual / / Semi-annual / / Waiver of Premium/Waiver Monthly Deduction
/ / Quarterly / / Check-O-Matic Monthly / / Accidental Death Benefit $________________
Automatic Premium Loan.............../ / Yes / / No / / Spouse Protection Rider (SPR)________units
List Billing (minimum 5 lives) / / Children's Protection Rider (CPR)____units
Bulk Billing / / New / / BB# _____________ / / ACT Rider $_______________________________
Pension Trust / / New / / PT# _____________ / / Other $
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6 FOR INDETERMINATE PREMIUM POLICY ONLY: I understand that:
(a) the current premium for the policy applied for may change after the initial guarantee period:
(b) the current premium then charged is not guaranteed and the Company may charge the full maximum
guaranteed premium / / YES
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7 a. Beneficiary(ies) (Give full legal Name and Date of Birth) Relationship to Proposed Insured
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b. Contingent Beneficiary(ies) (Give full legal Name and Date of Birth) Relationship to Proposed Insured
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8 INSURANCE NOW IN FORCE (IF NONE, STATE NONE) AMOUNT AMOUNT ADB YEAR OF ISSUE
COMPANY NAME
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Is the insurance applied for intended to replace, change or borrow against any insurance or annuity in this
or any other company? / / YES (If, "Yes," give company, policy number and amount)
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10 HOME OFFICE ENDORSEMENT SPECIAL REQUESTS:
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Form 1092
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11 a. Does any person proposed for insurance have any applications for life insurance now pending? Yes No
If "Yes," give Company, kind, amount and Owner/Beneficiary / / / /
b. Has any person proposed for insurance ever had an application for life or health insurance
or reinstatement declined, rated, modified, postponed, withdrawn or canceled? / / / /
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12 Has any person proposed for insurance, in the past 3 years engaged in, or do they expect to
engage in any hazardous or dangerous activities such as: hang gliding, flying ultra lights,
mountain climbing, ballooning, racing (automobile, go-karts, midgets, cycle, boat, snowmobile),
white water rafting or diving (skin, scuba, sky)? If "Yes," complete Avocation Questionnaire. / / / /
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13 Has any person proposed for insurance ever flown or do they intend to fly as a pilot or crew
member? If, "Yes," complete Aviation Questionnaire. / / / /
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14 Does any person proposed for insurance intend to travel or reside outside the country except
for vacation? If, "Yes," answer where, why and duration in Remarks. / / / /
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FOR QUESTIONS 15 AND 16, If "Yes," give details plus driver's license number and state in REMARKS Section.
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15 In the past 3 years, has any person proposed for insurance been charged with:
a. any motor vehicle violations other than parking violations? / / / /
b. driving under the influence of alcohol and/or drugs? / / / /
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16 Has any person proposed for insurance ever had their driver's license restricted, revoked
or suspended? / / / /
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17 Has any person proposed for insurance ever been convicted of a felony or misdemeanor? If "Yes,"
provide details. / / / /
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18 Is any person proposed for insurance in the Reserves, National Guard or on active duty in the
military? If, "Yes," provide details. / / / /
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REMARKS - USE WHERE MORE SPACE IS NEEDED.
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Question No. Details
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19 AMOUNT PAID WITH THIS APPLICATION: $ _______________ IN EXCHANGE FOR CONDITIONAL PREMIUM RECEIPT
/ / NONE BEARING THE SAME NUMBER AS THIS APPLICATION.
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AGREEMENT. The Proposed Insured and the Applicant, if other than the Proposed
Insured, represent, each to the best of his/her knowledge and belief, that all
statements and answers contained in this application and any amendments thereto,
are true and correctly recorded and expressly agree as follows: (1) This
application (Part 1, and any other required part(s), shall be the basis for and
a part of any policy issued; (2) No information acquired by. any representative
of the Company shall bind the Company unless set out in writing in this
application; (3) No contract of the Company can be made, modified or discharged,
nor may any of its rights or requirements be waived, except in writing signed by
its President, Vice President, Secretary or Assistant Secretary; (4) Except as
otherwise provided in the Conditional Premium Receipt bearing the same number as
this Part 1, no insurance shall take effect until a policy is issued and
delivered to the Owner and the full first premium paid, all while the health and
other conditions affecting the insurability of each person on whom insurance is
requested remain as described in this application; (5) The Company may indicate
changes for administrative purposes only in the space for Home Office
Endorsement in the application. The acceptance of any policy issued on this
application shall constitute acceptance and ratification of any such changes. No
changes shall be made in the amount of insurance, classification of risk, plan
of insurance, benefits, beneficiaries or ownership without written consent of
the Proposed Insured and Owner.
The Applicant, if other than the Proposed Insured, otherwise the Proposed
Insured, shall be the Owner of any policy issued hereon.
ACKNOWLEDGMENT. If a premium deposit is tendered with the application, the
Proposed insured and the Applicant, if other than the Proposed insured represent
that he/she has carefully read the Conditional Premium Receipt and understands
and agrees to the terms thereof including the conditions under which a limited
amount of insurance may become effective prior to policy delivery.
AUTHORIZATION. I hereby authorize any licensed physician, medical practitioner,
hospital, clinic, or other medical or medically related facility, insurance
company, the Medical Information Bureau or other organization, institution or
person, that has any records or knowledge of me or my children for whom
insurance application is made, or my health, or their health, to give to
RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY, or its reinsurers any such
information. I further authorize RELIASTAR BANKERS SECURITY LIFE INSURANCE
COMPANY to request that an investigative consumer report be prepared as
described in the notice given to me. If a consumer report is prepared, I elect
to be interviewed. / / No.
I acknowledge receipt of, and have read, the Notifications given to me. This
Authorization is valid for 30 months from the date this form was signed. A
photographic copy of this authorization shall be as valid as the original.
Signature of
Signed at: ______________________ Date:______________ Proposed Insured:____________________________________________
(If age 15 or over - Parent if under age 15)
Signature of Spouse
_____________________________________________________ or Other Insured: ___________________________________________
Signature of Agent as Witness
Signature of
Applicant (Owner): __________________________________________
_____________________________________________________________
(If a Firm or Corporation or Trust insert name and title)
-------------------------------------------------
APPLICATION RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY
NON-MEDICAL 0000 Xxxxxxxx Xxxx, Xxxxxxxx, XX 00000
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PART II
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1 a. Name of Proposed b. Date of Birth x.Xxx d. Height _____ ft.
First Middle Last Month Day Year / / M _____ in.
/ / F Weight _____ lbs.
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2 Who is your doctor (if none, so state). How Long ? Address
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Date of last visit Reason What did he tell you about his findings?
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3 Have you ever had or do you now have any disease, disorder, or injury of the following or any sickness
listed below: (Circle item(s) and give details under question number 4.) Use Additional Remarks section
if needed.
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Yes No Yes No Yes No
Stroke or dizziness / / / / Heart murmur, rheumatic fever / / / / Diabetes or sugar in urine / / / /
Paralysis or epilepsy / / / / High blood pressure / / / / Cancer, tumor, cyst or polyp / / / /
Convulsions or fainting / / / / Liver, gallbladder, hepatitis / / / / Lymph gland, thyroid or other / / / /
Brain, nervous system / / / / Stomach, ulcers, hernia / / / / endocrine disorder / / / /
Nervous or mental disorder / / / / Pancreas, Intestines / / / / Anemia or other blood disorder / / / /
Lungs, bronchitis, asthma / / / / Colitis, diverticulitis / / / / Eyes or skin disorder / / / /
Shortness of breath / / / / Rectum, rectal bleeding / / / / Arthritis, neuritis, gout / / / /
Tuberculosis, pneumonia / / / / Kidney, bladder, kidney stone / / / / Bone, joint or muscle disorder / / / /
Heart or blood vessels / / / / Prostate, reproductive organ / / / / Sexually transmitted or venereal / / / /
Chest pains or palpitations / / / / Blood, pus or albumin in urine / / / / disease, except for AIDS / / / /
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4 Give diagnosis, date of each occurrence, duration, current status and names and addresses of doctors and
medical facilities
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Give details in Additional Remarks Section.
(dates, results, doctors consulted and addresses, etc.) Yes No Additional Remarks
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5 a. Are you at the present time taking any medication? / / / /
b. Are you presently under a doctor's care for any condition? / / / /
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6 Has your weight changed more than 10 pounds in the past year? / / / /
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7 Have you ever had or do you now have chronic or unexplained fatigue,
malaise, lass of appetite, diarrhea, fever of unknown origin, severe
night sweats, unexplained or unusual infections or skin lesions,
unexplained swelling of the lymph glands, Kapposi's Sarcoma or Pneumocystis
Carinii Pneumonia? / / / /
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8 Have you been diagnosed or treated by a member of the medical profession
for Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex
(ARC)? / / / /
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9 Other than above, have you in the past 5 years:
a. Had any mental or physical disorder not listed above? / / / /
b. Had a check-up, consultation, EKG, X-ray, or other diagnostic
procedures, except for AIDS, illness, injury or surgery? / / / /
c. Been a patient in a hospital, clinic or other health care facility? / / / /
d. Been advised to have any diagnostic test, treatment, hospitalization
or surgery that was not completed other than an HIV test? / / / /
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10 Have you ever requested or received a pension, benefits, or payment
because of an injury sickness or disability? / / / /
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11 Have you ever used cocaine, heroin, barbiturates or any illegal, restricted or
controlled substance or any other drugs except as prescribed by a
doctor or other licensed practitioner; or received treatment or advice
from a doctor or other practitioner regarding the use of drugs except
for medical purposes; or received treatment, counseling or advice from
an organization which assists those who have a drug problem? / / / /
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NM 2092
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Give details in Additional Remarks Section.
(dates, results, doctors consulted and addresses, etc.) Yes No Additional Remarks
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12 Have you ever:
a. Used alcoholic beverages? If "Yes," how often, how many ounces, and
for how many years? / / / /
b. Been advised to reduce or discontinue the use of alcoholic beverages? / / / /
c. Been counseled, sought help or treatment, or been advised to go for
treatment or counseling for alcoholism or drug use? / / / /
d. Attended or joined any organization such as Alcoholics Anonymous (AA)
or Narcotics Anonymous (NA) for alcohol and/or drug related problems? / / / /
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13 Family History:
Is there history of diabetes, heart disease, high blood pressure, cancer,
kidney disease, mental illness, suicide, or any hereditary disease? / / / /
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14 a. Age if Living Age at Death Cause of Death b. Brothers and Sisters:
Father: ________________________________________________________________ No. Living: ____
Mother: _______________________________________________________________ No. Dead ____ Cause ______
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ADDITIONAL REMARKS (CONTINUED)
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Question No. Details
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I represent that all statements and answers to the foregoing questions are, to
the best of my knowledge and belief, complete and true. I agree: (a) that they
shall form a part of my application; (b) that they shall be subject to the terms
of the agreement found in Part I; and, (c) that they shall become a part of any
policy based on this application.
Signed at: _______________________ Date: ____________ Signature of
City and State Proposed Insured:_______________________________________
_____________________________________________________
Signature of Agent as Witness
-------------------------------------------------
PART III RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY
LIFE APPLICATION 0000 Xxxxxxxx Xxxx, Xxxxxxxx, XX 00000
MULTIPLE INSURED SUPPLEMENT -------------------------------------------------
(Use on Riders: Spouse, Dependent Children,
Other Insured below $100,000)
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1. Name of Spouse (or Other Insured) Soc. Sec. No. Date of Birth Sex Birthplace Hgt. Wt.
First Middle Last Month Day Year
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2. Dependent children proposed for Relationship
insurance.
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HEALTH STATEMENTS (The following questions must be answered on all the above Proposed Insured) - Give details
of all YES answers in Remarks Section.
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3. Has any person named above used tobacco in any form
in the past twelve months? / / Yes / / No
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4. Has any person named above lost more than 10 pounds
in the past year? / / Yes / / No
How much? Reason?
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5. Has any person named above ever received treatment
or counseling for alcohol or other drug usage, or been
a member of any self-help group, such as Alcoholics
anonymous or Narcotics Anonymous? / / Yes / / No
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6. Does any person named above, to the best of your
knowledge, have any mental or physical impairment or
disease? / / Yes / / No
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7. Who is the family doctor? (If none, state none)
Name: _______________________________________________
Address: ____________________________________________
_____________________________________________________
Phone No.: __________________________________________
Date last seen: ___________ Why? ____________________
For which proposed insured? _________________________
What tests were made? _______________________________
With what results? __________________________________
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8. Has any person named above ever had, currently have
or been treated for:
a. High blood pressure? / / Yes / / No
b. A heart condition? / / Yes / / No
c. Chest pain / / Yes / / No
d. Stroke? / / Yes / / No
e. Diabetes? / / Yes / / No
f. Cancer? / / Yes / / No
g. Respiratory Condition? / / Yes / / No
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9. Has any person named above:
a. Consulted a doctor or other medical practitioner in
the last five years? / / Yes / / No
b. Had any electrocardiograms, blood studies,
(excluding any study or test for HIV), or other
medical tests or studies within the last five
years? / / Yes / / No
c. Been diagnosed or treated by a member of the
medical profession for Acquired Immune Deficiency
Syndrome (AIDS) or AIDS-Related Complex (ARC)?
/ / Yes / / No
d. Been under observation or received treatment in
any hospital or other institution in the last five
years? / / Yes / / No
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10. Is any person named above currently taking, or been advised to take, any medication? / / Yes / / No
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11. REMARKS - DETAILS OF ITEMS 3 THROUGH 10. Give complete information including where applicable, name
of person, dates, number of attacks, duration, results, and names and addresses of doctors, medical
facilities, etc.
QUESTION NO. | DETAILS
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I represent that all statements and answers to the foregoing questions are,
to the best of my knowledge an belief, complete and true. I agree: (a) that
they shall form a part of my application; (b) that they shall be subject to the
terms of the agreement found in Part I; and,(c) that they shall become a part
of any policy based on this application.
AUTHORIZATION: I hereby authorize any licensed physician, medical practitioner,
hospital, clinic or other medical or medically related facility, insurance
company, the Medical Information Bureau or other organization, institution or
person, that has any records or knowledge of me or my children for whom
insurance application is made, or my health, or their health, to give to
RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY, or its reinsurers any such
information. I further authorize RELIASTAR BANKERS SECURITY LIFE INSURANCE
COMPANY to request that an investigative consumer report be prepared as
described in the notice given to me. If a consumer report is prepared, I elect
to be interviewed. / / No
I acknowledge receipt of, and have read, the Notifications given to me. This
Authorization is valid for 30 months from the date this form was signed. A
photographic copy of this authorization shall be as valid as the original.
Signed at: ____________________ Date: _____________ __________________________________________________________
City and State Signature of Spouse or Other Insured, if any otherwise
Signature of Proposed Insured Who Signed Part I.
____________________________________________________
Signature of Agent as Witness
Form 3092
AGENT'S REPORT
(WRITING AGENT MUST COMPLETE THIS FORM IN ALL CASES)
------------------------------------------------------------------------
1. How long have you known the Proposed Insured?
____________ How well? _____________________________
2. a. Did you personally see all persons proposed for insurance?
/ / Yes / / No
b. Was the application signed by the persons proposed for
insurance after all questions concerning health and habits
were answered?
/ / Yes / / No
Explain if "No":
_________________________________________________________
_________________________________________________________
3. If Proposed Insured is a juvenile:
a. Does he/she live with his/her parents? / / Yes / / No
b. Are all brothers and sisters insured for
like amounts? / / Yes / / No
If no, explain: _________________________________________
c. How much insurance is in force on the life of the person
responsible for the child's support $___________
4. a. This application is being submitted:
/ / Non-Medically / / Super Non-Med / / Medically
b. Have you arranged for the medical requirements;
/ / Yes / / No
c. Name and telephone number of Examining Service the
requirements were scheduled with: _______________________
_________________________________________________________
5. Is the Insurance applied for intended to replace change or
borrow against any insurance or annuity in this or any other
company?
/ / Yes / / No
If "Yes," submit all required forms.
6. Has an application of any person proposed for insurance been
submitted to other Companies in the past year?
/ / Yes / / No
Explain if "Yes."
____________________________________________________________
____________________________________________________________
7. What is the Proposed Insured's:
a. Annual Earned Income? $_____________________
b. Unearned Income? $_____________________
c. Financial Net Worth? $_____________________
8. Do you know anything, not stated in the application that
might affect our decision to offer insurance?
/ / Yes / / No
Explain if "Yes"
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
------------------------------------------------------------------------
I represent that the above information is true and complete to the best of my
knowledge and belief, and that the application has been completed in accordance
with RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY'S rules, guidelines and
instructions. I certify that I have given the Proposed Insured the notification
about the Federal Fair Credit Reporting Act/Abbreviated Notice Regarding
Insurance Information Practices and the Medical Information Bureau. If I become
aware of a change in the health or habits of any person proposed for insurance,
occurring after the date of the application but before I deliver the policy, I
promise to inform RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY of the
changes and I agree to withhold delivery of the policy until instructed by
RELIASTAR BANKERS SECURITY LIFE INSURANCE COMPANY.
-------------------------------- -------------------------------- --------------------------------
Print Agent's Name Agent's Signature Code No.
-------------------------------- -------------------------------- --------------------------------
Print Agent's Name Agent's Signature Code No.
-------------------------------- -------------------------------- --------------------------------
Print General Agent's Name General Agent's Signature Code No.
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MARKETING INFORMATION:
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1. List the ages of Proposed Insured's children:
____________________________________________________
____________________________________________________
2. How was the prosect developed: (Circle One)
1) Canvass 2) Direct Mail 3) Applicant Inquiry
4) Referral 5) Other ___________________________
3. The Proposed Insured: (Circle One)
1) Owns a home 2) Rents a home 3) Neither
4. The sale of this insurance is part of a plan for:
(Circle One)
1) Retirement or pension 5) Cash accumulation
2) Family Income 6) Final expenses
3) Payroll deduction 7) Estate planning
4) Mortgage insurance 8) Other (specify)
__________________
5. Annual household income is: (Circle One)
1) Under $25,000 4) $75,001 - $100,000
2) $25,000 - $50,000 5) $100,001 - $150,000
3) $50,001 - $75,000 6) Over $150,000
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