PROPOSAL / APPLICATION INDIVIDUAL ACCIDENTAL DEATH INSURANCE

Transcription

1 PROPOSAL / APPLICATION INDIVIDUAL ACCIDENTAL DEATH INSURANCE Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey Phone: (201) or (800) / Facsimile: (201) SUBMISSION CHECKLIST All questions, including all Part III Medical History questions, are answered completely and/or acknowledged regardless of whether or not they apply. All Yes answers include details in the space provided (i.e. dates, diagnosis, names and addresses of physicians, medication prescribed, present condition, etc.). Pilot / Flight History Questionnaire has been completed, signed and dated by the Proposed Insured (if applicable). Any answers crossed-out or covered with white-out are initialed by the Proposed Insured. Part III Medical History has been signed and dated where indicated on Page 4 by the Proposed Insured. Agreement has been signed and dated where indicated on Page 6 by the Proposed Insured and Proposed Policy Owner (if applicable). Authorization to Release Information has been signed and dated where indicated on Page 7 by the Proposed Insured and Proposed Policy Owner (if applicable). Agent Statement has been signed and dated where indicated on Page 7 by the Producing Agent. Producing Agent is already appointed with Hanleigh. If not, please contact Hanleigh at the number above. Lloyd s Privacy Policy Statement Form LSW 1135 has been delivered to the Proposed Insured. A copy of the Illustration is attached. This checklist has been provided for your convenience. Compliance with these instructions will significantly reduce unnecessary underwriting delays. Incomplete applications may be denied and returned at Underwriters discretion. Thank you for your cooperation!

2 PROPOSAL / APPLICATION INDIVIDUAL ACCIDENTAL DEATH INSURANCE Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey Phone: (201) or (800) / Facsimile: (201) PART I GENERAL 1. Proposed Insured s Name: Residence: City: State: Zip: Date of Birth: Place of Birth: Sex: Social Security Number: 2. Name of Proposed Owner: Address of Owner: Relationship to Proposed Insured: Name of Beneficiary: (if other than Owner) Address of Beneficiary: Relationship to Proposed Insured: 3. Proposed Insured s Occupation: Duties and Description Occupation: Annual Earned Income: Unearned Income: Net Worth: 4. (A) Has any application for accident, sickness, life, disability or long-term-care insurance submitted on behalf of the Proposed Insured ever been declined, (B) postponed Has an Insurer or withdrawn? ever modified, canceled or refused to renew such coverage? (C) If Yes, to (A) or (B) complete the following: Type of Insurance: Company Name: Policy Number: Date and reason: HMI APP-ADD 0901 Page 1

3 5. Do you engage in any hazardous sports, hobbies or avocations, e.g., auto racing, scuba diving, hang gliding, bungee jumping, parachuting, roller blading, technical climbing, etc.? If Yes, note the type of activity involved: 6. Are there any other circumstances connected with your occupation, past-times, or any other matter which may render you liable to accident or illness? If Yes, please explain: PART II TRAVEL & AVIATION The following information is to be completed by the Proposed Insured. Please answer to the best of your knowledge and belief. 7. Do you anticipate traveling overseas during the term of this policy? If Yes, please provide details (i.e. location, duration, nature of travel): 8. How many flights do you anticipate during the next twelve (12) months by: Commercial airlines? Private airplane? Helicopter or other aircraft? 9. Do you anticipate flying as a pilot or crewmember of any aircraft during the term of this policy? If Yes, a supplemental Pilot/Flight History Questionnaire must be completed. PART III MEDICAL HISTORY 10. Have you ever been treated for, or ever had, any known indication of: (Check applicable items.) (A) Disease of eyes or ears? Details of Yes answers (Identify Question. Include diagnoses, dates, duration and names and addresses of all attending physicians and medical facilities.) HMI APP-ADD 0901 Page 2

4 Details of Yes answers (Identify Question. Include diagnoses, dates, duration and names and addresses of all attending physicians and medical facilities.) (B) Dizziness, fainting, convulsions, headache, paralysis or stroke, transient ischemic attack (TIA), mental or nervous disease? (C) Neurological disease or disorders, Alzheimer s, Parkinson s, ALS, tremors, numbness, or Multiple Sclerosis? (D) Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack, congestive heart failure or other disease of the heart or blood vessels? (E) Diabetes, thyroid or other endocrine disease? (F) Deformity, lameness or amputation? (G) Anemia or other disease of the blood? 11. Have you ever been treated for the use of, or are you currently using, habit-forming drugs? 12. Have you within the past 5 years: (A) Had any psychiatric or physical disease not listed above? (B) Had a checkup, consultation, illness, injury, surgery? (C) Been a patient in a hospital, clinic, sanatorium, or other medical facility? HMI APP-ADD 0901 Page 3

5 Details of Yes answers (Identify Question. Include diagnoses, dates, duration and names and addresses of all attending physicians and medical facilities.) (D) Had electrocardiogram, X-ray, other diagnostic test (except for an HIV test)? If yes, please advise results. (E) Been advised to have any diagnostic test, (except for an HIV test) hospitalization or surgery, which was not completed? 13. Have you ever been diagnosed or treated by a medical professional for AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS Related Complex) in the past 10 years? 14. Are you now under medical observation or taking treatment? Have you been advised to seek treatment or has treatment been recommended for any condition? 15. Have you ever requested or received a pension, benefits, or payment because of an injury, sickness or disability? If so, please describe the type of disability, the length of disability and the Insurance Carrier. Length of Disability: Type of Disability: Insurance Carrier: 18. Statement of height and weight: Height: feet inches Weight: pounds I represent that the statements and answers above in Part III Medical History are true, complete and correctly recorded to the best of my knowledge and belief. In some states we are required to inform you that: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act which may be a crime, shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Proposed Insured s Signature: HMI APP-ADD 0901 Page 4

6 PART IV BENEFIT SECTION Benefit Schedule: Benefit Schedule is subject to Company approval. Next to each item in the Benefit Schedule below, insert an X in the appropriate box and complete the blank spaces. Accidental Death & Dismemberment: Principal Sum Term of Insurance Accidental Death Only: Principal Sum Term of Insurance NOTICE TO PROPOSED INSURED/OWNER PART ONE Information regarding the Proposed Insured s insurability will be treated as confidential. Hanleigh Management, Inc., Hanleigh General Agency, Inc. ( We ) may, however, make a brief report thereof to the Medical Information Bureau Inc., 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 submit a claim for benefits to such a company, the Bureau, upon request, will supply such company with information in its file. We may also release information in its file to other insurance companies to whom the Proposed Insured and Proposed Owner may apply for life or health insurance or to whom a claim for benefits may be submitted. PART TWO In the course properly underwriting and administering this insurance coverage, We will rely heavily on information provided by the Proposed Insured and the Proposed Owner (if other than the Proposed Insured). We may also seek information from others, such as medical professionals, who have treated the Proposed Insured. In some cases, We may ask a consumer-reporting agency to collect information and submit an investigative consumer report to us. The Proposed Insured has the right to request to be interviewed in connection with the preparation of that report. The Proposed Insured may receive a copy of the report upon request. Information regarding the Proposed Insured s insurability will be treated as confidential. In some situations, and in compliance with applicable law, We may disclose necessary items of information to third parties without the Proposed Insured s specific authorization. The Proposed Insured has the right to be told about, and to see and copy if he/she wishes, items of personal information which appear in our files, including information contained in investigative consumer reports. The Proposed Insured also has the right to seek correction of information that he believes to be inaccurate. HMI APP-ADD 0901 Page 5

7 AGREEMENT IT IS UNDERSTOOD AND AGREED THAT: 1. We shall incur no liability under this Application unless a Policy is issued on this Application and the full First Premium is actually paid based on the continued insurability of the Proposed Insured as stated in this Application. 2. To the best of my knowledge, information and belief, all statements and answers in this Application are full, complete, and true and correctly recorded and bind all parties of interest to the Policy herein applied for. 3. The Proposed Insured and the Proposed Owner (if other than the Proposed Insured) also agree to provide financial statements, which shall also become a part of this Application. 4. The Proposed Insured and the Proposed Owner (if other than the Proposed Insured) also agree to provide proof of an insurable obligation or interest (as evidenced by a valid contract or agreement), which shall also become a part of this Application. 5. The acceptance of the Policy by the Proposed Insured and the Proposed Owner (if other than the Proposed Insured) will ratify any Underwriters Additions or Corrections including amendments of amount, risk, classification, age at issue, plan of insurance or benefits. However, in those states where written consent is required, any such amendment will be made only with the written consent of the Proposed Insured and the Proposed Owner (if other than the Proposed Insured). 6. No agent or medical examiner or other person, except Underwriters at Lloyd s, London, or an officer of Hanleigh Management, Inc. or Hanleigh General Agency, Inc. is authorized to make or discharge contracts or waive or change any of the conditions or provisions of any Application, Policy or receipt or to accept risk or pass upon insurability. Notice to or knowledge of any agent is not notice to or knowledge of Underwriters at Lloyd s, London, or Hanleigh Management, Inc., Hanleigh General Agency, Inc. unless stated in this Application. The Proposed Owner, if any, otherwise the Proposed Insured, shall be the Owner of any Policy issued hereon. Signature of Proposed Insured: Signature of Proposed Owner (if other than Proposed Insured): Relationship: HMI APP-ADD 0901 Page 6

8 AUTHORIZATION TO RELEASE INFORMATION I hereby authorize any physician, medical practitioner, hospital, clinic, veterans administration facility, medical information service including Medical Information Bureau, Inc., urgent care facility, other medically related facility or entity, insurance or reinsurance, or Consumer Reporting Agency having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition including drug or alcohol abuse, and/or treatment of me or my dependents and other non-medical information of me, to release to Underwriters at Lloyd s, London, and/or Hanleigh Management, Inc., Hanleigh General Agency, Inc., or its designee any and all such information. This authorization includes release of information concerning psychiatric/psychological conditions and preparation of an investigative consumer report. I understand that the information obtained by use of the authorization will be used by Underwriters at Lloyd s, London, and/or Hanleigh Management, Inc., Hanleigh General Agency, Inc., to determine eligibility for insurance or to determine eligibility for benefits under the Policy. Any information obtained will not be released by the Insurer except to reinsuring companies, insurance support organizations or other person or organizations performing business or legal services in connection with my application, or as may be otherwise lawfully required. I know that I may request to receive a copy of this authorization. I know that I may request to be interviewed if any investigative consumer report is prepared in connection with this application. I agree that a photographic copy of this authorization shall be as valid as the original. This authorization shall be valid for twenty-six (26) months from the date signed. Signature of Proposed Insured: Signature of Proposed Owner (if other than Proposed Insured) Relationship: AGENT STATEMENT I certify that I have truly and accurately recorded all the information given to me by the applicant, and I certify that I know of no other medical information about the person applying for coverage other than that contained on this application. I certify that the applicant has either filled out the application or has personally reviewed the completed application. I have explained all policy benefits, exclusions and limitations. Producing Agent s Signature: Producing Agent s Name (please print): Agency Name: HMI APP-ADD 0901 Page 7

9 PRIVACY POLICY STATEMENT Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey Phone: (201) or (800) / Facsimile: (201) UNDERWRITERS AT LLOYD S LONDON We, the Certain Underwriters at Lloyd s, London that have underwritten this insurance want you to understand how we protect the confidentiality of nonpublic personal information we collect about you. INFORMATION WE COLLECT We collect nonpublic personal information about you from the following sources: a) Information we receive from you on applications or other forms; b) Information about your transactions with our affiliates, others or us; and c) Information we receive from a consumer-reporting agency. INFORMATION WE DISCLOSE We do not disclose any nonpublic personal information about you to anyone except as is necessary in order to provide our products or services to you or otherwise as we are required or permitted by law (e.g., a subpoena, fraud investigation, regulatory reporting etc.) CONFIDENTIALITY AND SECURITY We restrict access to nonpublic personal information about you to our employees, our affiliates employees or others who need to know that information to service your account. We maintain physical, electronic, and procedural safeguards to protect your nonpublic personal information. CONTACTING US If you have any questions about this privacy statement or would like to learn more about how we protect your privacy, please contact the agent/broker who handled this insurance. LSW 1135