HAWKINS v. GLOBE LIFE AND ACCIDENT INSURANCE COMPANY, No. 1:2013cv07814 - Document 29 (D.N.J. 2015)
Court Description: OPINION. Signed by Magistrate Judge Joel Schneider on 5/12/2015. (Attachments: # 1 Court's Exhibit A-D)(tf, )
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HAWKINS v. GLOBE LIFE AND ACCIDENT INSURANCE COMPANY Doc. 29 Att. 1 r1 rQ -H 0 U Dockets.Justia.com A Fariy atsfiec1 PaicyhoIdtr Globe Life And Accident Insurance Company stands out for its valuable products and quality customer service. Since 1951, Globe Life has grown in financial strength and reputation. With over 3.8 million policyholders, (Iobe Life Is comm itted to providing affordable life Insurance for the entire family . Toda Globe Life has over $58 billion of Insurance in force. Globe Life continues to receive high national ratings from independent insurance analysts AM. Best Company: A÷ (Superior) AM. Best Company, insurance analysts since 7899. This rating Is based on their latest analysis of Globe Life’s financial strength. management skills and IntegrIty (rating as of 6/10). For the latest rating, access www.ambest.com. — POliCY DESCRiPT1ON This is a modified premium term•to -age-9 The lnitlaltenn pedodcan either be 1,2, 34cr 5 yeats In duration, 0 product, upon Issue age. All renewal term periods begin at a 5-year plus depending one and will be 5 yeats In length except for the age (I.e. period. The final 4-year period always begins at age 86 and the final term terminate at the policy anniversary following the insured’s 90thpolicy will bIrthday. 21, 26, 31, 36.J61 MIS, INc. PRE•NOTiCE InformatIon regardIng your Inswab aty will be treated as confidential Globe tile And Accident Insurance Company, or Its telnaurers may. hoer,makeabriepotthereoneMlS,lncfornerlykno wnestheMedlcal Information Bweau,anot-for.pro& membership orgarsicatlon ol Insurance companies. which operates an Information euchange on behalf of Its members another MIS menther company fot tife or health kstrirance coverage,IF ydu apply to or a claim for beneiltulu submitted to such a company, MIS. upon request, wlH supp’ such company with the lnforniattott about you Inks file Upon receipt of a request from you, MIS will arrange disclosure of any Information In yourflhe.lf you have questIons, please contact MIS at 866492690! IflY866-346-3642) It you question the accuracy of the Information In MIS’s file, you may contact MIS and seeR a correction In accordance with the procedures ses forth iii the federal Fair Credit RepoflingAct. The address otMIrr Information office Is SOSraintree HIlIPark. Suite 400, Bralnlree. Massachusetts 02! 544734. Globe Lila And Accident Insurance Company, or its relnsur rs, nay also ueI,ana Information from its file to other Insurance companIes whom to yoa may apply for life or health lnwearscn. or to whom a c1im for benefit may be submitted. Information s tot contumess about MIS may be obtained on its webtit e at www.mlb.com Gtobe Lit, kid Accident lnswanc Company Is licemid In all staten except New Yorlt. Globe Life And Acssdp sclnsurance Company Globe Life Center . p1aboma City, OX 73184 97Z4AT4542 Policy Fom NGRTG or SR1tV with GThêOWGTCADRIO reeso R4151 mexjustnwar aihøah qütbns a. 3c1ay money”back gurantee 1’ flr*4ay coveräg*] BydItect by mall .‘ NWakin. period wI_ —— Choose $5,000, $10,000, $20,000, $30,000 or $50,000 Coverage a) U C. It U In C -I It .0 0 4.0 0 0 It 4’ in C 0 4’ to ‘a a a It It E a 0 2.. 1%) 0 C >0 in e 2’ 61 -o C - r.flwl.w I -. -- - V !: a— n Ct I’ll m -H -H 41 U) 0 U [A Fami’y 01 Satisfied PoyFok1ec Globe Life And Accident Insurance Company stands out for its valuabl products and quaUty ajgomarseMce, SInce 1951, Globe Ufe his gréwn In financial strength and reputation. With over 3.8 mlUlon pobqiiolders, Globe Life Is committed to rovldkig affordaNe life Insurance for the entire family. today, Globe Life has over $58 billion of Insurance In force. Globe Life continues to receive high national ratings from Independent Insurance analysts AlA. Best Company At tSup.rlor) AM. Best Company, Insurance analysts since 1899, ThIs raring Is based on their latest analysis of Globe Life’s financial strength, management skills and Integrflyttatlnq as of 6/10). for the latest rating, access www.amb.st.com. - POLiCY 0E5CPDOti Thu Iii modfled premium renn-oage-90 product. adanetthatbe 1,Z3.4o5ekidwadofl.depatdnQ Thelninalterm upon Isteat age. AS re wal teem periods begin it a 5.yei pite one age (La. 21, 2fl 3), 36_861 and wIll be S seats hi length ancept be the final term peilod. The final 4-.eat period always begins cage 86 and the policy wIll terminate at the policy anolveney folawing the Insured’s 90th bIrthday. —-I - MR INC. perNoT)Ce Irdaimatbt mgar.ig ow frwrrablNj wi be betted an con&leMaI. Gdse Lie And AatkMit Utsureice Cempeay, at Na ndrawwa may, howair. mW a beNt report dieter., die P hic. bemety bateti at the MedIcal IrdaimailanIarnaane4atpmflInembe&Ipo,gakernncecompanbe. wNth apeielei in b*emaden nge on betiti at Na meeibei W ydu apply to ‘ amiha, WI membet caineery be We at heIdi kantiatice cayerege. at a diNt fat t,a AtheIttadepiticli acatn.pwy, ho. upon requae. win pplysr4a company nation abc with the u hi itt Pie. MI wit anwtgedsdostn of any Infatmatlan In U1xtn rl(tJ* of a repieg horn yaurftlciyaubeve quantlana. plem niaa WI at 8664*2-6301 (V1Y1W346-36421. ift qwabn the accuracy with, lriiatmaoon It k*Wa file. yeu may contact MI aid teeN. cenullon In aczordance with di. pcocedurth iet fonit N the fedeqi tab Cr,t fepoitIng Art iheaddins oIMlVi *nutlandflcela SO NuwI4f Path. Sulte400. irIrOn. Massachusatu 071143734. Globe CO. And Accident Iniwance Conipatiy. at its ,elnsum,L may also ‘alms. Inransiatan 1mm Iii fda tooth., bflwaqtce compeees Ia witontimu may apply be We or htllth rOwaflcI or to whatrn a cben fat b,ntftIs may be wbn4rtad tttaniadin fat cans wean about NIl nay be eNteerd an 4) etbite at wr4icco4 GINa Lit. Md AcddetO kiewatati Caq N Catted hi NI IW*3 unapt Mitt Yai*. Globr Life And Acdej nsurance Company Globe Life Center pJ,J*ma City. OK 73184 Pclb. Fomi GRIG at SRTCV mitt aTtAOnIGU.AOWQ he&ttl quesbL*s C-’. asedycovag6 p C .t Pi,waieInçperl4 . Choose $5,000, $10,000, $20000, S30.000ur $50,000 Coverage a, U U Ub -J 0 w 4.. t C 0 m 4.1 ‘a 0. w E 0. 0 h. U 0 C I -a w C JIIIILLIJJ [[11 ii’ . . ij .ro liP - -cJ- - GLOBE LIFE AND ACCIDENT INSURANCE COMPANY * Oklahoma City, Oklahoma 73184 A Legal Reserve Stack Company ‘Globe Life Center GROUP RENEWABLE TERM LIFE INSURANCE POLICY Globe Life And Accident Insurance Company certifies that it has issued Group Policy GRTG, and that the person named In thIs certificate is Insured, subject to the terms and conditions of the Group Policy. DEATH BENEFIT PAYABLE We will pay the proceeds at this certificate to the Beneficiary when We receive due proof that the lnsumd’s death occurred while this certificate was in force. 30 DAY RIGHT TO EXAMINE CERTiFICATE Your certificate carefully. Within 30 days after this certificate Is first received, It may be Please examine returned to Us. If returned, the certificate will be as though it had never been issued. My premiums paid will be returned. THIS IS A LEGAL CONTRACT - READ YOUR CERTIFICATE CAREFULLY In this certificate: means an eligible person who is named In the Certificate Specifications. Insured means the Owner of the Certificate. You. Your We. Us, Our—— means Globe Life And Accident insurance Company. means age an the last birthday of the Insured. Age —— —— -- Signed for Globe Life And Accident insurance Company at Oklahoma City. Oklahoma. President Secretary The basis for this certificate Is the information in the enrollment farm. Incorrect PLEASE READ information In the enrollment farm could void the certificate or cause an otherwise valid claim to be denied. Advise Us Immediately if any information is wrong or If any pest medical historyhas been left out. — CERTI FICATE SPECIFICATIONS GROUP POLICY NUMBER: HOLDER: GRTG-1 GLOBE FAMILY SERVICES TRUST INSURED: CERTIFICATE NUMBER: KhaUl L Wallace CERTIFICATE EFFECTIVE DATE: 00-3T50404 OCTOBER 01, 2011 19 MALE ISSUE AGE AND SEX: PREMIUM CLASS: STANDARD AMOUNT OF INSURANCE: $50,000 REINSTATEMENT INTEREST RATE: 6.00% BENEFICIARY: AS STATED IN THE ENROLLMENT FORM, UNLESS SUBSEQUENTLY CHANGED BY THE CERTIFICATE HOLDER. GROUP RENEWABLE TERM LIFE INSURANCE POLICY Renewable and Convertible for the periods shown on Page 2 Premiums Payable as shown on Page 2 Amount of insurance Payable as shown on Page 2 Non—Participating No Dividends are paid. — - — — - BENEFIT_AND PREMIUM SCHEDULE DESCRIPTION OF BENEFITS: END OF INITIAL TERM PERIOD: RENEWAL TERM PERIOD: END OF CONVERSION PERIOD: AMOUNT OF INSURANCE: METHOD OF PAYMENT ELECTED: PREMIUMS: PREMIUM PERIOD BEGINNING MONTHLY PREMIUM OCTOBER 01, 2011 NOVEMBER 01. 2011 OCTOBER 01. 2013 OCTOBER 01, 2018 OCTOBER 01, 2023 OCTOBER 01, 2028 OCTOBER 01, 2033 OCTOBER 01. 2038 OCTOBER 01, 2043 OCTOBER 01. 2048 OCTOBER 01. 2053 OCTOBER 01. 2058 OCTOBER 01, 2063 OCTOBER 01, 2068 OCTOBER 01, 2073 OCTOBER 01, 2078 OCTOBER 01, 2082 ertIfIcate Specifications lanefit and Premium Schedule kmount of Proceeds iwner and Beneficiary remiums and Reinstatement RENEWABLE TERM TO AGE 90 OCTOBER 01, 2013 5 YEARS OCTOBER 01, 2057 $50,000 ANNUAL $1.00 $13.74 $16.49 $19.24 $21.99 $27.49 $32.99 $47.49 $67.49 $101.99 $142.99 $193.99 $268.99 $319.49 $563.99 $807.49 END OF RENEWAL PERIOD TABLE OF CONTENTS Page I Renewal 2 Conversion 3 General Provisions 3 Payment of Proceeds 3 Page 3 3 3 3 AMOUNT OF PROCEEDS e proceeds payable at the death of the Insurid will be: (a) the Amount of Insurance provided by this rtIf)cate on the date of death of the In.ured less (b) the portion of any premium due and unpaid iich applies to a period prior to the date of death at the Insured. OWNER AND BENEFICIARY HTS OF THE OWNER — This certificate belong, to You, the Owner. Unless You provide otherwise, u may receive all benefits and exercise all rights granted by this certificate durIng the Insured’s tIme. NERCIARY it no named Beneficiary survives the Insured, the proceeds will be paid to the Owner, if Ing; otherwise to the Owner’s estate. ANGE IN CERTIFICATE OWNER AND BENEFICIARY - Unless You provide otherwise In writing to Us, u may change the Owner or BeneficIary during the lifetime of the Insured. Changes must be made written request filed with Us. The change whO take effect on the data the request was signed, but it - I not apply to payments made by Us before WI accept the request In writing. SiGNMENT - You may assign this crtfficate. However, no assignment will bind U. until it is flied In Iting at Our Home OffIce. When ft Is filed, Your rights and the rights of any Beneficiary will be j.ct to it. We will not be rssponsihl. for the validity of any assignment fGC Page 2 GRTGCOO2 PREMIUMS AND REINSTATEMENT PREMIUMS Premiums ate payable In advance at Our Home Office. We will issue You a receipt upon request GRACE PERIOD This certificate has a 31—day grace period. This means that if any premium after the first is not paid on at before the date It Is due, it may be paid during the followIng 31 days. During the grace period the certificate will stay in force. At the end of the grace period, the Certificat. will lapse. REINSTATEMENT If Your certificate lapses You may ask that it be put back In force. We will do provided: (a) Your written request Is received at Our Home Office within one year of the due date so of the first unpaid premium; (b) You show that the Insured ii still Insurable according to Our normal rules; and Cc) You pay all overdue premiums, plus compound interest at the reinstatement interest rate shown on page 1. RENEWAL if this certificate is in force at the end of a term period, it may be renewed by payment of the renewal premium shown In the Benefit and Premium Schedule of the certificate on page 2 Renewal effective upon payment of that premium within 31 days of its due date. Each Renewal Term will be Period shall begin at the end of the preceding term period and will be for the period of time shown on pags 2. CONVERSION You may exchange this certificate for an individual life policy without evidence of insurability, provided that: (a) this certificate is in forca; fb) the certificate anniversary following the Insured’s 65th bIrthday has not passed; and (C) You submit a written application for the conversIon, The new policy will be issued: (a) on a level premium whole life plan; fb) far an amount of insurance equal to or less than the insurance provided by this certificate en the date of exchange; Cc) at a premium according to Our rates then in use for the age of the Insur.d and Cd) In the same premium class as this certificate. Riders may be included in the new individual polIcy only with Our consent TERMINATION OF COVERAGE The coverage of any Insured shall terminate at the end of the Grace Perläd following any premium due date for which the insured’s required premium has not been paid. Any premium paid foi any period after the date coverage terminates will not continue the Insured’s coverage in force and will be returned. Coverage will automatically terminate on the Certificate Anniversary as shown In the Benefit and Premium Schedule on Page 2. GENERAL PROVISIONS THE CONTRACT This certificate, including the enrollment form, is the entire contract between You and Us. Any change must be made In writing by on. of Our officers. All statements In the enrollment form are representations and not warranties. No statements shall be used to void this certificate or to defend against a claim unless contained in the enrollment form. PAYMENT OF BENEFITS All benefits are payable at Our Home Office. We may require You to submit this certificate before We approve changes or pay benefits. ERRORS IN AGE OR SEX If the Insured’s age or sex is misstated, the benefits under this certificate will be those the premium paid would have purchased at the correct age and sex. SUICIDE EXCLUSION if the Insured commits suicide, while sane or Insane, within two years from the certificate date Our liability will be limited to the premiums paid. INCONTESTASILIW This certificate will be incontestabl, after it has been in force during the lifetime of the Insured for two years from the Certificate Effective Data except for non—payment of premiums. PAYMENT OF PROCEEDS PAYMENT UPON PROOF OF DEATH We will pay the life insurance proceeds in one sum subject to due proof of the Insured’s death and of the claimant’s interest Such proof must be submitted on forms acceptable to Us. OTHER PAYMENT OPTIONS While the insured is living, You may elect to receive the life Insurance proceeds in any other manner agreed to in writing by Us and may change or revoke such election. At the time the proceeds become payable, a Beneficiary may elect to receive the proceeds in another manner agreed to in writing by Us subject to the Owner’s right to restrict payment CLAIMS OF CREDITORS To th, extent permitted by law, proceeds will not be subject to any claims of creditors of the Inaurad or Beneficiary. — — - — — — — — — - — GRTGC Page 3 GRTGCOC GLOBE LIFE AND ACCIDENT INSURANCE COMPANY Globe Life Center * Oklahoma City, Oklahoma 73184 EXTENDED TERM INSURANCE RIDER This Rider amends and Is made a part of the certificate to which It Is attached. it Is subject to all provisions, conditions, exclusions and limitations of the certificate which are not in conflict with this rider. NONPAYMENT OF PREMIUM: If a premium is not paid by the end of the grace period. the certificate will lapse as of the due date of the overdue premium. All Insurance will terminati at the time of lapse unless the certitlcateholder qualifies for EXTENDED TERM INSURANCE. The cartlflcatehoid.r qualifies for such If: 1) the certitlcateholder has an attained age of 55 or older on the due date of the overdue premium, and 2) the certificate for which premiums are due has been In effect tot at least ten years as of the due date of the overdue premium. The length of the EXTENDED TERM INSURANCE will be one year from the due date of the overdue premium. The amount of the Extended Term insurance will be the amount of insurance of the attached certificate. Secretary Praildent C) rt H H Cl) rt ‘1 0 n Globe Life And Accident Insurance Company. Globe Life Center’ Okiahome City, 01(73184 Dear Friend: Answer A Few Yes/No Health Questions 0 No Waiting Period 0 Buy Direct By Mall No-Risk Money-Back Guarantee Join Over3.8 Million Current Globe Life Policyholders RE: $50,000 Adult Life Insurance Globe Life gives you life insurance coverage that costs only $1 .00* to start! You can choose $5,000, $10,000, $20,000, $30,000 or even $50,000 coverage. There’s no medical exam just answer a few Yes/No health questions. We provide you with easy-to-understand information and you determine the amount of protection you need for your family. It’s Easy To Buy Just Answer A Few Yes/No Health Questions Getting life insurance does not have to be time-consuming. You buy directly through the mail just answer a few Yes/No health questions on the easy application. It’s — — hassle-ftee. $ 100* Starts Up To $50,000 Life Insurance Coverage Pay only $1 .00* for the first month whether you choose $5,000, $10,000, $20,000, $30,000 or $50,000 coverage. After the first month, the rate schedule Is based on your current age and is guaranteed for the life of the policy. See the enclosed brochure for our affordable monthly rates. Your Life Insurance Coverage Can Never Be Canceled Or Reduced Your life insurance benefit will NEVER be canceled or reduced throughout the policy period because of changes in your health or occupation as long as your premiums are paid on time. Your coverage is a term-to-age-90 life insurance policy and the beneficiary you 5elect is paid directly, FREE of federal income tax. Your FULL protection starts the first day your policy Is issued. There is no waiting period. Supplement Your Existing Life Insurance Supplement your own existing life insurance or life insurance provided by your employer. The FULL benefit is paid by Globe Life in addition to any other coverage. A Globe Life policy provides up to $50,000 of financial support for hospital and doctor bIlls, funeral costs plus other final expenses when your loved ones need It most. Up To $150,000 Accidental Death Protection Option You can also choose $25,000, $50,000, $100,000 or $150,000 accidental death protection for your family for a few dollars more per month, if you are between the ages of 18 and 69. Established 1951 Built On Honesty, Reliability And Trust - CONFIDENTIAL GLOBE_0007 22 F Simply indicate the coverage amount in the space provided at the boom of the enclosed application. If you choose this optional accidental death insurance, your $ 1.00* also pays for this additional coverage for the first month. Answer A Few Yes/No Health Questions No Waiting Period Buy Direct. No-Risk 30-Day Money-Back Guarantee Complete the application, sign and mall it with $ 1.00*. Once your application is approved, we will mail your policy. If you are not satisfied for any reason, return it within 30 days and we’ll refund your $1 .00* no questions asked. — Globe Life Is Rated A+ (Superior) By A.M. Best Company Globe Life currently insures over 3.8 million policyholders with over $60 billion of insurance in force and has made life insurance easy to buy since 1951. Globe Life continues to receive an A+ (Superior)t rating from A.M. Best Company, one of America’s leading insurance analysts since 1899. This rating is based on their latest analysis of Globe Life’s financial strength, management skills and integrity. Globe Life is the life insurance company you can trust. By Mail S No-Risk Money-Back Guarantee Make this important decl5ion today. Remember, you are protecting your future and the future of the ones you love. Sincerely, Join Over 3.8 Million Current Globe Life Policyholders Charles F. Hudson President CH:qon R7/1 1 R5. Remember, your spouse or another family member can also get life insurance protection. We’ve included another application for them to apply. Please be sure that you both sian the aopllcations. *Rates alter the first month are shown In the enclosed brochure. tRating as of 6/11. For latest rating, access www.ambest.com. Policy Form #GRTG or SRTCV with GTLADR or GTLADR1 0 ONFIDENTIAL GLOBE_COOl 23 Court’s Exhibit D U ii I z D 0 oS 0 >- -J -J U U z P z a, a C,) I 0 E a a C C :I: 0 ••;•z ..J 0 0 0 uJI 0 -3 C, J I— U] z z U 0 0 atfl4 • ‘ $1 Buys Upiö $50,000 ADuuua’EIN$uHANa Your insurance Informatôn ““• i enclosed’ •.‘ cuww flwlT1fluP (WH1 AIDRB NBOLLMENT FOB LIFE 1NSURAt4CE IM1ORTAr+t Pl,sao be mx eecti qpas,tlea em Ibe Proposed Insured Name otimmit form is earewered FirSt, MI., Last) Please Pray eu ,ai / , ci Mole Dtamalo $5,000 £3 $10.000 [3 $20,000 Ø$5o,000 [3150,000 Apt. Address City Telephone State____________ Zip E-mail M&ess I (ICiprn id t-, M*fla fr Cletie, bent,, Un Ody) Reletlonwhip to Proposed Insired lPt,enw Pitill B.eultelany Name lPLqeea pihuli Please answer the totlowing queailon& A “yea response does not automatically make you Inaflble for Is the Proposed Insured currently disabled due to illness, confined to a hospital or nursing facility, or does the Roposed Insurod rOqulno the use of a wheelchair” 2. In the past 3 years, has the Proposed Insured had or been treated for: (a) Cancer, coronary ertery disease, or any disease or disorder 01 the heart, I• brain or livOr” kidney faiture. muscular disease, mental or nervous disorder, chronic obstructive lung disease, drug or alcohol abuse, or hospitalized for diabetes? (c( Acquired Immirre Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or test results indicating exposure to the Acquired Immune Deficiency Syndrome 3. Does the Proposed Insured have any chronic illness Or condition which requires periodic medical care or may require Iutre surgery? 4. Does the Proposed Insured intend to replace or change any existing life insurance policies or anrajities in connection with this enrollment” If yes, liSt company name: (b) Chronic kidney disease coverage. Ci Ci Ci Ci or Ci Ci Ci Ci AUThORIZATIOM I en anclrxtis Ire Laitiat pielnuil rat enlemlaud tie insuseca aroliad lvi wit become eltedivd as the ate this enroibsent kiss is wpraaed by te Carcary &era at listens at tie kissed Sli&ld Us enraleSni karl be dechued. 1w anearl paid wit be rebated I bratty Satanse Mth Inc. vi has siy eccoth at as a my bo5l0 aid any ratsiacy berwib sasaer thai possesses presoripllm bailey steal me, La lve any and sudi kilainalen to Oldie Lilt Md Accident hosarce Canpany. Health inkanalia, isidaid wtl rid be adoclanad withsst my MreizaUm ertem penudLted by isa, Is wivich case rmy ad be mWcidd undaa tederal priuzy rides This autiodralies abet be valid be two heal ban lis date and ray be revoked by serdr wsuftefl roOts to Obese Lila Md Accdeul Hemaice Calyary. I zkIrewltHee acolyt slat MIS, Inc PNcles A Hlaio9rapli copy al this sinsizaben wuli be as valid an tie ariptoal. My parsim avis lackiat sly laIai kiloimallan as an appkcailoy Is a, traurars, policy Is sdi(ecl to civnbral and dull porathe YESI I want additional Accidental Death coverage In the amount of: (For ag 18-69, please chock C $50,008 for $5.00 morn per month U $25,080 let $2.50 more per month par month C $150,080 tot $15.00 more per month C $100,000 lot $1000 ona1 more ? DATE Thu sTatunin wilT civok 766X29) CONFIDENTIAL or non APPLIC*NT - OWNErS S1ONATUPS, LA5lONai4rrS TO PRCWQS01) INUU Matre area payable to Slabs Liii Md Accidea knisance tampion ancuid St mallet is ire inner mounds aciolid GLOBE_000f 20 $1 Buys $50,000— Direct By Mail • It’s easy to apply. You can choose from $5,000, $10,000, $20,000, $30,000 or even $50,000 life insurance coverage. • Please answer each of the questions on the apicatlon. There is no medical exam • For just a few dollars more per month, you can add $25,000, $50,000, $100,000 or $150,000 of accidental death coverage to your policy if you are between the ages of 18 and 89. • Enclose $1 .00* with the application and mail in the free postage-paid envelope ie • No waiting period. Protection starts as soon as your policy is issued. The policy pays regardless of death, except suicide, while sane or insane it suicide occurs within two years from the date of issue Cone year in CO and ND; not applicable in MO). Mioeanlolh,sex.nc. tCfa.c,sO,et (Frst. Ml., Lall Pva Print as Mdross City / /a Ule D.UUD5W.OOO QU,DOD Drareid 0 P30.000 fl$50,000 .Apt. State____________ Zip Telephone E-mail Address (ICflSU* awe FeeS AUwU 1k ..l.m. 1klaI 1k. Banaficarp Plea.. aaswer 1. just a few Yes/No heaith to fill out below. Be sure gh applicant signs their application. provided for your convenience. We make It easy to apply. Proposed lr.__. — questions. If YOU Want coverage for your spouse or other family members, we have included an additional application Name (Thems PaM) sey) ReIMion.hip to Proposed Ineured Pheese Feint) lb. following question.. A “yes° rsepons. doe, not automatically make you Ineligible lot covarag.. the Proposed Inanired currently dIsabled due to kness, confined to a hoapltal or nursing tacitly, or does the Proposed Insured require the use of a wheelchair? 2. In the past 3 years, has the Proposed Insured had or been treated for: (a) Cancer, coronary artery disease, or any disease or disorder of the heart, brain or liver? tbl Chronic kidney disease or kidney failure, musculer disease, mental or nervous disorder, chronic obstructive lung disease, drug or alcohol abuse, or hospitaUzed for dIsbetes (c) Apoulred immure Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or test results indicating exposure to the ttcquired immune Deficiency Syndrome virus? 3. Does the Proposed insured have any cia-onic illness or condItIon which reqtires periodic rnedit:al care or may reqLre future sugary? 4. Does the Proposed Insured Intend to repIsce or change any mdstlng life Insunsnce policies or arviulties in connection with this enrollment? Is If yea, list I] C] C] CI CI CI CI CI CI CI company name: AUTHONIZATION I air encobi Fe Feibe prairkjn aid Lintel lid Fe ianLanice eppiled tar will becam idIethe ai Fe dale ha eaervrwn,f ken 5 approved by Fe Cnri,any dsgis tie iileanw 01 Fe frsenij Shaibj Fe ortolmed an,, be deslaeet the anteed paid will pa rekjidtd I hafeby slant l.fl Inc. lit han sly ecorth a) ow or my fma*. aid any piunnany beretils maner Fe possesses taecripliar history lad nan is ue any oral all ssidi a Ge Oh And 1ccdeil Ferne Ganpany. eater Atoerpala, nisaaied will red be ieditc1a,eei what my atIiaiaaUn slides painted by law, ir wkch case) ray nat be prabecled slider tahersi pdvzy alat. INs aitmhra1 slat be vaild or lao ban ella asis and my be rmnked by oeridir wades stirs is GkDe Ole kid Accident eouaoa Coirpay. I xblosledg• scald of tie t.llO. 1st, PreNlaca A l*icçncdr copy at this aiirrsilim well b as valid an tie aigr Any parom 4rt wcbrdes any false nlamla an an apptcaflan we an roursece policy is slcI is cnninal aid clvi poralhes. YES! I addItIonal AccIdental Death coverage In the amount of: (For ac 16-69, please check $25,000 lot $2.50 more per month u $50000 tar $5.06 mat, per month $100,000 tar $10.00 more put month 0 $150,000 far $15.00 mare per month want i DATE Thb wroIIn*l) one.) y wih Lirstis a cash shOuld Si mailed In the edorn emvelape .stlose) Malie ideck paydhle to athe ide Arid Aslhteid lieorence Corpery. Policy Form IGRTG or SRTCV with GTIADR or GT)ADRIO CONFIDENTIAL GLOBE_000I 21
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