Please be advised that this is a sample life insurance policy only. Actual Policies may differ by state and underwriting criteria.
Standard Juvenile Whole Life
Congratulations:
Your Globe Life Young American application for Sample S Name has been approved, and your policy is enclosed. The Globe Young American Plan is life insurance for a lifetime, regardless of future health, military service, or occupation.
You have started a whole life insurance policy that can never be canceled as long as the regular premiums are paid. This guarantees Sample S Name future insurability. The enclosed policy provides Ashley with a lifetime of protection.
Please take a moment and verify the information you provided. You will find a copy of the application at the back of your policy.
If any information is wrong, please contact us by calling (405) 270—1410 and ask one of our customer service representatives for assistance. Or if it is more convenient for you, e—mail us at cs@2701410.com and provide us with the corrected information. If everything is correct, sign your application. Then place this policy in a safe place.
You will receive a premium due notice about 15 days before your next premium is due unless you selected the credit card or bankdraft payment option. Then your premium will be periodically deducted when it is due.
We’re proud to have you as a member of the Globe family of satisfied policyholders. Your decision to start a Young American Plan for Ashley is a wise one. It demonstrates the love you have for Ashley.
Thank You for Choosing Globe.
Mark McAndrew
Chairman & Chief Executive Officer
Beneficiary Designated is: 00—M12345
Applicant Sample Policy
For S Policy
123 Main Street
Anywhere, USA 00000
GLOBE LIFE AND ACCIDENT INSURANCE COMPANY
Privacy Policy
Globe Life And Accident Insurance Company cares about protecting its policyholders’ privacy. In the process of providing the products and services you requested, we will collect, use and share certain information you or other persons provided. This Privacy Policy explains what information we collect and how we use that information. The policy also explains how we protect the security and confidentiality of your information.
Collection of Information
We collect and retain the information necessary for us to provide the products and services you requested. In that process we may collect non-public information from you as a result of your completion of an insurance application or other forms, information about your transactions and experience with us, or from a consumer reporting agency such as the Medical Information Bureau. We may also collect personal information about you from other persons or entities.
Sharing Information
We may share information with certain non—affiliated companies or individuals, including providers inquiring about benefits, family or legal representatives acting on your behalf, and to comply with legal or regulatory requirements. We may also share information about you with non—affiliated entities that contract with us to perform marketing and administrative services. We may also disclose your information to our affiliated companies. The information disclosed without your authorization will be only as much as is reasonably necessary to accomplish the intended purpose.
Your Right To Access
You can request to be informed as to the nature and substance of personal information we collect about you. You can also request that we correct, amend, or delete any such information.
Internal Protection of Information
We restrict access to non—public personal information about you to those employees who need to know that information to provide the products and services you requested. We maintain physical, electronic and procedural safeguards to comply with federal regulations to guard this information.
Disclosure of Our Privacy Policy
We are sending you this Notice for informational purposes and may amend this Privacy Policy at any time and will update it as required. We post our current privacy notice at www.globeontheweb.com.
CALIFORNIA LIFE AND HEALTH INSURANCE
GUARANTEE ASSOCIATION ACT
SUMMARY DOCUMENT AND DISCLAIMER
Residents of California who purchase life and health insurance and annuities should know that the insurance companies licensed in this state to write these types of insurance are members of the California Life and Health Insurance Guarantee Association (“CLHIGA”). The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guarantee Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided through the Association is not unlimited, as noted in the box below, and is not a substitute for consumer’s care in selecting insurers.
The California Life and Health Insurance Guarantee Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy.
Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus.
Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Guarantee Association to induce you to purchase any kind of insurance policy.
Policyholders with additional questions should first contact their insurer or agent or may then contact:
Executive Director
California Life and Health Insurance Guarantee Association
P.O. Box 70069
Los Angeles, CA 90070
or
Allegra Willison, Staff Counsel
California Department of Insurance
45 Fremont Street, 24th Floor
San Francisco, California 94105
The state law that provides for this safety—net coverage is called the California Life and Health Insurance Guarantee Association Act. On the back of this page is a brief summary of this law’s coverages, exclusions and limits. This summary does not cover all provisions of the law nor does it in any way change anyone’s rights or obligations under the Act or the rights or obligations of the Association.
COVERAGE
Generally, individuals will be protected by the California Life and Health Insurance Guarantee Association if they live in this state and hold a life or health insurance contract, or an annuity, or if they are insured under a group insurance contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state.
EXCLUSIONS FROM COVERAGE
However, persons holding such policies are not protected by this Guarantee Association if:
* Their insurer was not authorized to do business in this state when it issued the policy or contract;
* Their policy was issued by a health care service plan (HMO, Blue Cross, Blue Shield), charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society.
* They are eligible for protection under the laws of another state. This may occur when the insolvent insurer was incorporated in another state whose Guarantee Association protects insureds who live outside that state.
The Guarantee Association also does not provide coverage for:
* Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which guarantee rights to group contract holders, not individuals;
* Employer or association plans, to the extent they are self—funded or uninsured;
* Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus;
* Any policy of reinsurance unless an assumption certificate was issued;
* Interest rate yields that exceed an average rate;
* Any portion of a contract that provides dividends or experiences rating credits.
LIMITS ON AMOUNT OF COVERAGE
The Act limits the Association to pay benefits as follows:
LIFE AND ANNUITY BENEFITS
* 80% of what the life insurance company would owe under a life policy or annuity contract up to
* $100,000 in cash surrender values,
* $100,000 in present value of annuities, or
* $250,000 in life insurance death benefits.
* A maximum of $250,000 for any one insured life no matter how may policies and contracts there were with the same company, even if the policies provided different types of coverages.
HEALTH BENEFITS
* A maximum of $200,000 of the contractual obligations that the health insurance company would owe were it not insolvent. The maximum may increase or decrease annually based upon changes in the health care cost component of the consumer price index.
PREMIUM SURCHARGE
Member insurers are required to recoup assessments paid to the Association by way of a surcharge on premiums charged for health insurance policies to which the Act applies.
NOTICE TO CONSUMERS
Should any dispute arise concerning your coverage, contact the agent or write to:
GLOBE LIFE AND ACCIDENT INSURANCE COMPANY
Globe Life Center
Oklahoma City, Oklahoma 73184
(405) 752—5500
If the problem is not resolved, You may then contact:
Consumer Affairs Division
California Department of Insurance
300 South Spring Street
Los Angeles, CA 90013
The toll—free Consumer Hotline Number is 1—800—927—HELP (4357).(Calling from within California).
Los Angeles area and outside California (213) 897—8921.
TDD — Telecommunications Device for the Deaf (800) 482—4833.
IMPORTANT
YOU HAVE PURCHASED A LIFE INSURANCE POLICY. CAREFULLY REVIEW IT FOR LIMITATIONS.
THIS POLICY MAY BE RETURNED WITHIN 30 DAYS FROM THE DATE YOU
RECEIVED IT FOR A FULL REFUND EITHER BY RETURNING IT TO THE
AGENT OR THE INSURANCE COMPANY. AFTER 30 DAYS, CANCELLATION
MAY RESULT IN A SUBSTANTIAL PENALTY, KNOWN AS A SURRENDER CHARGE.
GLOBE LIFE AND ACCIDENT INSURANCE COMPANY
ADMINISTRATIVE OFFICES: GLOBE LIFE CENTER ** OKLAHOMA CITY, OKLAHOMA 73184
A Legal Reserve Stock Company
We will pay the proceeds from this policy when we receive due proof that the Insured died while this policy was in force.
The consideration for this policy is the application and the first premium.
This policy is issued and accepted subject to all the provisions set forth on the following pages.
We have put this policy into effect as of the date of issue. Policy years, premium due dates, and policy anniversaries are measured from the date of issue.
Modified Premium Whole Life Policy — Insurance Payable at Death of Insured — Non—Participating Premiums Payable During Life
POLICY SPECIFICATIONS
PREMIUM SCHEDULE
ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY
FIRST 3 MONTHS -- -- -- $1.00
THEREAFTER $120.00 $62.40 $31.80 $10.80
OWNER: The owner of this policy is the applicant unless a different owner is designated in the application.
BENEFICIARY: The beneficiary shall be as designated in the application unless changed as provided in the policy.
INSURING AGE: 02 DATE OF ISSUE: 08/03/04
INSURED: Sample S Name POLICY NUMBER: 00—M12345
AMOUNT OF INSURANCE: $30,000
READ YOUR CONTRACT CAREFULLY. This is a legal contract between you and Globe Life and Insurance Company. The contract sets forth, in detail, the rights and obligations of both you and us. IT IS,
THEREFORE, IMPORTANT THAT YOU READ YOUR CONTRACT CAREFULLY.
This LIFE INSURANCE contract provides death protection for as long as you live. Premiums for this contract are payable as shown on the Policy Specification page.
ALPHABETIC GUIDE TO YOUR CONTRACT
Page Page
Actuarial Basis..................................................(6) Indebtedness & Repayment.................................(5)
Assignment.......................................................(4) Misstatement of Age (or Sex).............................(4)
Basis of Calculation.............................................(6) Non—Participation........................................(4)
Beneficiary..................................................(1),(3) Options Available........................................(5)
Cash Loans.......................................................(4) Ownership................................................(3)
Change of Plan...................................................(4) Payment of Proceeds......................................(4)
Contract (The)...................................................(2) Premiums.................................................(2)
Definitions......................................................(2) Reinstatement............................................(3)
Grace Period.....................................................(3) Suicide Exclusion........................................(4)
Incontestability.................................................(4) Table of Loan and
Nonforfeiture Values...................................(6,7)
GENERAL PROVISIONS
DEFINITIONS
The Insured — The person whose life is insured under this policy while the policy is in force.
You, Your — The current Owner of this policy, unless changed as allowed in the policy. The Owner has all the rights this policy provides unless otherwise stated in the policy.
We, Us, Our — Globe Life and Accident Insurance Company at its Administrative Office in Oklahoma City, Oklahoma.
Proceeds — The amount we pay when the Insured dies or the policy matures. The proceeds equal the amount of insurance minus any indebtedness on the policy.
Insuring Age — The age of the Insured at his or her last birthday on the Date of Issue.
Attained age — The insuring age (shown on the Policy Specifications page) plus the number of years and completed months since the date of issue.
THE CONTRACT
Read your policy carefully. This policy is a legal contract. The entire contract is this policy and the attached application. Unless fraudulent, all statements made by or on behalf of anyone covered by this policy are representations and not warranties. No statement can cancel this policy or be used in our defense if We refuse to pay a claim unless it is found in an attached application.
The provisions of this contract can be changed only by a written agreement signed by Our President, a Vice President, our Secretary, or an Assistant Secretary.
We are not bound by any promise or representation made by an agent or anyone else.
PREMIUMS
The Policy Specifications page shows the premium schedule. The first premium is due by the date of issue. You can pay a premium before its due date. Premiums are payable at Administrative Office or to an authorized agent.
If you wish, you can pay premiums every 12 months, every 6 months, every 3 months, or every month.
However, each payment must be at least $10.00. You can change your mode of payment on any premium due date by paying the correct premium for the new mode.
GRACE PERIOD
If You do not pay a premium by its due date, You have 31 days in which to pay it in full. We call this the grace period. The policy stays in force during the grace period. If the Insured dies during the grace period, We deduct the unpaid premium from the proceeds.
If You do not pay a premium by the end of its grace period, the policy will lapse. When lapsed, this policy is no longer in force, except as the Nonforfeiture Provisions provide.
REINSTATEMENT
If this policy has lapsed, You can reinstate it so that it provides coverage again. You have until 5 years after the due date of the unpaid premium to reinstate the policy. But You cannot reinstate it if You have surrendered it for cash.
To reinstate this policy, You must do all of these:
1. Provide proof which satisfies us that the Insured is insurable.
2. Pay all overdue premiums.
3. Pay interest on those premiums at a yearly interest rate of 6%, compounded annually.
4. Pay or reinstate any indebtedness which exists on this policy. (Interest charges from the date of lapse to the reinstatement will be at a yearly interest rate of 6%, compounded annually.)
BENEFICIARY
The beneficiary is the person or party named in this policy to receive the proceeds at the Insured’s death. While the Insured is alive, You can change the Beneficiary as often as you like. But You cannot change a Beneficiary who was named without the right of revocation.
To change a Beneficiary, file a satisfactory written request with Us. The change will take effect when recorded by Us. Once We record it, the change will take effect from the date You signed your request. But the change will not affect any payment We made or action We took before the endorsement.
OWNERSHIP
The applicant is the Owner of this policy unless a different Owner is named in the application. You have the right during the Insured’s life to receive every benefit and to exercise every right contained in the policy or allowed by us; but if any irrevocable Beneficiary has been named, his or her written consent shall be required before you may take any action concerning this policy.
The Owner may be changed or a contingent Owner may be named or changed by filing written notice with Us. We must approve the form and may require You to present the policy for endorsement. The change will take effect the day You sign the notice but it will not effect any action taken by Us before the notice is received at the Oklahoma City office.
If a contingent Owner and the Insured are both living when You die, the contingent Owner will become the new Owner. If no successive Owner survives, then at the Owner’s death, ownership shall vest in the Insured but if the Insured is a minor, his rights shall vest during his minority in the first—named Beneficiary. If the first—named Beneficiary is not living, the Insured’s rights shall vest during his minority in the parent or legally appointed guardian.
ASSIGNMENT
Only You may assign this policy. We are not bound by an assignment until it has been filed with Us. We are not responsible for the validity or sufficiency of an assignment A claim made under an assignment is subject to proof and the extent of the assignee’s interest. The interest of an assignee comes before that of a Beneficiary or survivor Owner. An assignee’s interest also comes before election of an option. An assignment is not a transfer of ownership. A assignee cannot change the beneficiary or exercise Ownership rights.
PAYMENT OF PROCEEDS
We pay the proceeds from this policy from our Oklahoma City Office. We first pay assignees. Then we pay the Beneficiaries based on the designation in force at death. If there is no designation or surviving Beneficiary, We pay the proceeds to the Insured’s estate. If a Beneficiary dies within 15 days after the Insured, but before the proceeds are paid, We pay the proceeds as though the Beneficiary had died before the Insured.
If benefits are payable to Your estate or to a beneficiary who cannot execute a valid release, We may pay benefits up to $3,000.00 to someone related to you or the beneficiary by blood or marriage whom We consider to be entitled to such benefits. We will be discharged to the extent of any such payment made in good faith.
INCONTESTABILITY
Unless You do not pay the premiums due, We cannot contest this policy after it has been in force during the Insured’s lifetime for 2 years from the date of issue. (This provision does not apply in the case of benefits allowed for total and permanent disability or accidental death.)
SUICIDE EXCLUSION
If the Insured, whether sane or insane, commits suicide within 2 years from the date of issue, We only refund the amount of the premiums already paid. (This provision applies for only 1 year in Colorado and North Dakota.)
MISSTATEMENT OF AGE (OR SEX)
In the event of misstatement of the Insured’s age (or sex), We will pay the Amount of Insurance that the premium paid would have purchased had the age (or sex) been correctly stated.
CHANGE OF PLAN
You can change this policy to another plan of insurance You and We agree upon at any time. The change must be according to Our rules. The amount of the new policy cannot be more than the amount of this policy at the time you ask for the change.
NON-PARTICIPATION
This contract does not participate in Our surplus or earnings.
LOAN PROVISIONS
CASH LOANS
You may use this policy as security to takeout a cash loan from Us. This policy must be in force and You must make us an assignee. The amount of the loan, plus interest through that policy year, can be as much as the loan value at that time. The loan value is:
a) The cash value at the end of that policy year, less
b) any unpaid part of that year’s premium, and less
c) the balance, plus interest, of all existing policy loans.
Interest on the loan will be the interest rate at 8% a year. Any overdue interest will be added to the loan and will bear interest at the same rate. We can defer granting a loan for the period law permits, but not beyond 6 months after We receive your loan application. We cannot defer granting a loan to pay premiums on one of Our policies.
INDEBTEDNESS AND REPAYMENT
The nonforfeiture values and proceeds are reduced by the amount of indebtedness on or secured by this policy. You can repay all or part of any cash loans, or loan interest any time before the end of the grace period for any unpaid premium. When the total amount of indebtedness equals or exceeds the loan value, the coverage from this policy will end. But it will not end until 31 days after We mail a notice to your last known address. We also notify any assignees We have on record.
NONFORFEITURE PROVISIONS
OPTIONS AVAILABLE
These nonforfeiture options are available to you once this policy has a cash value. If a premium is not paid when it is due, You can choose one of these options by filing a written request with Us within 60 days after the premium due date.
1. CASH SURRENDER: You can surrender this policy for its net cash value. The net cash value is the total of these:
The cash value shown in the Table of Loan and Nonforfeiture Values
(or an extension of it).
MINUS all indebtedness on this policy.
We can defer paying the cash surrender value for the period law permits, but We cannot defer beyond 6 months after the date of Your written request and surrender of the policy.
2. PAID—UP INSURANCE: You can continue this policy as non—participating paid—up insurance for a reduced amount. The new amount of insurance will be as much as the net cash value can buy at the net single premium rate for the Insured’s then attained age. The new amount of insurance will be payable at the same time and under the same conditions as this policy.
3. EXTENDED TERM INSURANCE: You can continue this policy as non—participating extended term insurance. The amount of coverage will be the total of these:
The amount of insurance as of the date of lapse under this policy.
MINUS all indebtedness on this policy.
We will use the net cash value to buy insurance for as long as possible at the net single premium rate for the Insured’s then attained age. The insurance will start with the due date of the unpaid premium. It will last for as long as the net cash value will allow.
We automatically continue this policy as extended term insurance if all of these apply:
1. A premium is not paid by the end of its grace period.
2. One of the other nonforfeiture options has not been chosen.
You do have the right to choose an option besides extended term insurance. But You must choose it within 60 days after the due date of the unpaid premium.
Insurance continued as paid—up or extended term will not include additional benefits provided by riders which may be attached to this policy. You can surrender paid—up and extended term insurance at any time. The amount You will receive will be equal to the net single premium for that insurance at the Insured’s then attained age. If the surrender is within 31 days after a policy anniversary, the cash value will not be less than on the anniversary.
BASIS OF CALCULATION
For the Insured’s attained age, the Table of Loan and Nonforfeiture Values shows the cash value. The cash value is the total of these:
The present value of future guaranteed life insurance benefits (not including additional benefit
attached supplementary agreements).
MINUS the present value of a life annuity which:
1. has a payment due immediately,
2. has annual payments equal to the nonforfeiture factors shown in the Table of Loan and Nonforfeiture values, and,
3. is payable during the remaining premium paying period.
A statement of how cash values for this policy are calculated has been submitted to the Insurance Department for your state.
The nonforfeiture benefits provided conform to the statutory minimum required by the state in which this policy is delivered.
ACTUARIAL BASIS
For this policy, We use the 1980 Commissioners Standard Ordinary Mortality Table—D (Age Last Birthday Modification) to calculate these:
1. Present Values.
2. Single premiums.
In all calculations, We assume these:
1. Interest at 5.75% a year.
2. Annual payment of premiums.
3. Deaths occurring at the end of policy years.
The net single premiums used for calculating the length of extended term insurance are based on mortality rates according to the 1980 Commissioner’s Extended Term Insurance Table—D (Age Last Birthday Modification).
TABLE OF LOAN AND NONFORFEITURE VALUES
This table shows the values available under the policy at the end of completed policy years. All values are subject to the amount of indebtedness on the policy. When you have paid premiums for part of a policy year, We adjust the values to fit the part paid for. If You ask, We will supply the values for any years not shown.
This policy is signed for Us by Our Secretary and President.
Secretary President
TABLE OF LOAN AND NONFORFEITURE VALUES
EXTENDED
POLICY AMOUNT OF CASH PAID-UP INSURANCE
YEAR INSURANCE VALUE INSURANCE YEAR DAYS
1 $30,000 $0.00 $0 0 0
2 30,000 0.00 0 0 0
3 30,000 0.00 0 0 0
4 30,000 0.00 0 0 0
5 30,000 0.00 0 0 0
6 30,000 0.00 0 0 0
7 30,000 0.00 0 0 0
8 30,000 30.00 612 0 263
9 30,000 96.00 1,872 2 94
10 30,000 168.00 3,138 3 270
11 30,000 240.00 4,296 5 14
12 30,000 318.00 5,460 6 164
13 30,000 390.00 6,432 7 307
14 30,000 468.00 7,422 9 225
15 30,000 546.00 8,334 11 249
16 30,000 624.00 9,174 13 355
17 30,000 708.00 10,020 16 204
18 30,000 792.00 10,800 18 359
19 30,000 882.00 11,574 21 52
20 30,000 978.00 12,348 22 358
NONFORFEITURE FACTORS ALL YEARS: 82.76430
LIFE INSURANCE SURRENDER COST INDEX LIFE INSURANCE NET PAYMENT COST INDEX
FOR 10 YEARS 3.46 FOR 10 YEARS 3.88
An explanation of the intended use of these indexes is provided in the Life Insurance Buyers Guide. The
indexes are useful only for the comparison of the relative values of two or more similar policies.
MODIFIED PREMIUM WHOLE LIFE POLICY - INSURANCE PAYABLE AT DEATH OF INSURED - NON-PARTICIPATING PREMIUMS PAYABLE DURING LIFE
FORM GWL1000
GLOBE LIFE AND ACCIDENT INSURANCE COMPANY
GLOBE LIFE CENTER * OKLAHOMA CITY, OKLAHOMA 73184
STATEMENT OF POLICY COST AND BENEFIT INFORMATION
POLICY NO. : 00-M12345 ISSUED ON THE LIFE OF: Sample S Name
POLICY TYPE : MODIFIED PREMIUM WHOLE LIFE
ISSUED AT THE INSURED’S AGE: 02
POLICY FACE ANNUAL GUARANTEED
YEAR AMOUNT PREMIUM CASH VALUE
1 $30,000 $91.00 $0.00
2 30,000 120.00 0.00
3 30,000 120.00 0.00
4 30,000 120.00 0.00
5 30,000 120.00 0.00
6 30,000 120.00 0.00
7 30,000 120.00 0.00
8 30,000 120.00 30.00
9 30,000 120.00 96.00
10 30,000 120.00 168.00
11 30,000 120.00 240.00
12 30,000 120.00 318.00
13 30,000 120.00 390.00
14 30,000 120.00 468.00
15 30,000 120.00 546.00
16 30,000 120.00 624.00
17 30,000 120.00 708.00
18 30,000 120.00 792.00
19 30,000 120.00 882.00
20 30,000 120.00 978.00
AT AGE 65 : The face amount is still $30,000.
The policy loan interest rate is 8 percent applied in arrears.
The Cost Indexes for this policy are as follows:
10TH YEAR 20TH YEAR
SURRENDER COST INDEX 3.46 2.99
PAYMENT INDEX 3.88 3.93
An explanation of the intended use of these indexes is provided in The Life Insurance
Buyer’s Guide.
If you have questions concerning this Policy Summary, direct your correspondence to:
Globe Life And Accident Insurance Co.
Globe Life Center
Oklahoma City, OK 73184
GLOBE LIFE AND ACCIDENT INSURANCE COMPANY
GLOBE LIFE CENTER * OKLAHOMA CITY, OKLAHOMA 73184
APPLICATION FOR LIFE INSURANCE
1. Proposed Insureds: (List Children Age 25 and under to be Insured)
First Name Middle Name Last Name Date of Birth Male or Female Face Amount
Child 1 Sample S Name 05/04/02 F $30,000
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8
2. Mail Policy and Premium Notice To:
Name: Sample Name
Address: 123 Main Street
City: Anywhere State: CA Zip: 00000
Telephone No. (555) 555-5555
3. Beneficiary: Unless otherwise requested, the Applicant shall be the beneficiary.
4. To the best of your knowledge and belief:
(a) Within the past 3 years have any of the Proposed Insured(s) had any chronic illness or condition which requires periodic medical care?..........................................................................................................................YES NO
(b) Have any of the Proposed Insured(s) ever been medically diagnosed or treated by a Physician for Acquired Immune Deficiency Syndrome (AIDS)?................................................................................................................................YES NO
Please list child and condition that caused yes answers to the questions above: ____________________________________________________
5. Will you replace or change any of your Life Insurance policies or annuity con tract in connection with this application?........YES NO
If yes, list company name: ______________________________________________________________
I AM ENCLOSING THE INITIAL PREMIUM FOR EACH PROPOSED INSURED AND UNDERSTAND THAT THE INSURANCE APPLIED FOR WILL BECOME EFFECTIVE ON THE DATE THIS APPLICATION IS APPROVED IN THE HOME OFFICE OF THE GLOBE LIFE AND ACCIDENT INSURANCE COMPANY. Should any Proposed Insured be declined, the amount paid for said individual will be refunded.
Signed At: ON FILE IN HOME OFFICE Date: 07/30/04
Signature:_________________________________
Relationship To Proposed Insured: ___________________________________________
Applicant
This is your Globe Life coverage.
Read carefully.
00-M12345
Sample Name
For S Name
123 Main Street
Anywhere, USA 00000