Supplemental Life Insurance Application

Transcription

1 Allianz Life Insurance Company of North America PO Box Minneapolis, MN Supplemental Life Insurance Application 1. Proposed Primary/First Insured First Name Middle Initial Last Name 2. Additional Beneficiary(s) - Proposed Primary/First Insured Percentages must total 100%; if you do not indicate the percentage, the surviving beneficiary(s) will share equally. For the Allianz Life Pro+ Survivor SM product, it is suggested that the proposed insureds do not name themselves as beneficiary(s) and instead consider naming another individual, trust, or entity. If beneficiary(s) are a Trust, include Trustee Name(s) and Trust Date. a. Type of Beneficiary: Individual Trust Corporation b. Type of Beneficiary: Individual Trust Corporation Primary Contingent c. Type of Beneficiary: Individual Trust Corporation Primary Contingent Primary Contingent If there are additional beneficiaries, please complete additional Supplemental Life Insurance Application(s) NB VA Page 1 of 9 (3/2017)

2 3. Proposed Additional Policy Owner Type of Owner: Individual Corporation Partnership Sole Proprietorship Trust Joint Non-Individual Owner Name First Name Middle Initial Last Name Relationship to proposed insured Male Female Address (street required) Date of Birth Social Security Number/Tax Identification Number City State ZIP Code Address Home Phone Number Alternate Phone Number (optional) Amount of Insurance Inforce on proposed policy owner Household Annual Income If Trust, provide Trustee Name(s) Household Net Worth Household Liquid Assets Household Annual Expenses Date of Trust 4. Proposed Contingent Policy Owner Type of Owner: Individual Corporation Partnership Sole Proprietorship Trust Joint Non-Individual Owner Name First Name Middle Initial Last Name Relationship to proposed insured Male Female Address (street required) Date of Birth Social Security Number/Tax Identification Number City State ZIP Code Address Home Phone Number Alternate Phone Number (optional) Amount of Insurance Inforce on proposed policy owner Household Annual Income If Trust, provide Trustee Name(s) Household Net Worth Household Liquid Assets Household Annual Expenses Date of Trust 5. Payor Billing statements will ONLY be sent to the address of the Payor. Payor Name Relationship to proposed insured Male Female Address (street required) Date of Birth Social Security Number/Tax Identification Number City State ZIP Code Address Home Phone Number Alternate Phone Number (optional) Amount of Insurance Inforce on Payor Household Annual Income Reason this Person is the Payor Household Net Worth Household Liquid Assets Household Annual Expenses NB VA Page 2 of 9 (3/2017)

3 6. Child Term Rider Insured a. Name Date of Birth Social Security Number/Tax Identification Number Phone Number b. Name Date of Birth Social Security Number/Tax Identification Number Phone Number c. Name Date of Birth Social Security Number/Tax Identification Number Phone Number d. Name Date of Birth Social Security Number/Tax Identification Number Phone Number 7. Proposed Other Insured/Second Insured First Name Middle Initial Last Name Male Female Address (street required) Date of Birth Age Social Security Number/Tax Identification Number Home Phone Number City State ZIP Code Address Place of Birth (state and country) Driver s License Number United States Other Annual Earned Income Annual Unearned Income Household Net Worth Household Liquid Assets Employer s Name Occupation/Duties State of Issue If married, spouse s Annual Income Household Annual Expenses Length of Employment If less than 2 years, provide previous employer, occupation and length of employment: If self-employed, include the type of business: Are you limited from working full-time? Yes No If Yes, provide details: NB VA Page 3 of 9 (3/2017)

4 8. Beneficiary(s) - Proposed Other Insured Rider Percentages must total 100%; if you do not indicate the percentage, the surviving beneficiaries will share equally. If beneficiary(s) are a Trust, include Trustee Name(s) and Trust Date. a. Type of Beneficiary: Individual Trust Corporation b. Type of Beneficiary: Individual Trust Corporation Primary Contingent 9. Replacement and Insurance Activity If replacing existing coverage, complete the applicable state Replacement Notification Amount of life insurance currently in force?... None Do you have existing life insurance or annuity contracts?... Yes No Amount of life insurance currently applied for, other than the amount being applied for on this application? Will this insurance replace any existing annuities and/or life insurance?... Yes No If yes, provide details below. If coverage will be replaced, will there be a surrender charge on the annuity or life insurance product?... Yes No If yes, what is the surrender charge percentage? Replacement 1: % Replacement 2: % Replacement 3: % Replacement 4: % Provide details of life insurance policy(s) or annuity contract(s) that are inforce or applied for below: Name of Company Face Amount Date Issued or Applied For Have you ever been charged an extra premium or been declined coverage with another company?... Yes No If yes, please explain: Type 1. Life Annuity Inforce Applied For 2. Life Annuity Inforce Applied For 3. Life Annuity Inforce Applied For 4. Life Annuity Inforce Applied For Primary If there are additional beneficiaries, please complete additional Supplemental Life Insurance Application(s) Contingent If applied for, will both policies be taken? To be Replaced? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No NB VA Page 4 of 9 (3/2017)

5 10. Nonmedical Questions - Proposed Other Insured Rider/Second Insured 1. Have you smoked one or more cigarettes or used any other form of tobacco/nicotine within the past 10 years?... Yes No If yes, include the date of last use, type of tobacco or nicotine, and amount used. 2. Do you drink alcoholic beverages?... Yes No If yes, provide frequency, number of drinks per occasion and type of alcohol used. 3. Are you a U.S. Citizen?... Yes No a. If no, do you hold a green card or Visa?... Yes No b. If yes, provide green card number or type of Visa: c. Indicate how long you have been in the U.S.: 4. Are you a member or do you intend to become a member of the armed forces, including reserves?... Yes No 5. Do you currently drive?... Yes No a. If yes, have you had any moving violations, including driving under the influence, or your driver s license suspended or revoked in the past 10 years? List date(s) and violation type(s)... Yes No 6. Have you ever flown or plan to fly as a pilot or student pilot? If yes, complete Aviation Questionnaire... Yes No 7. Do you intend to travel outside the U.S. or Canada within the next two years?... Yes No If yes, provide reason for travel, anticipated dates of travel, including frequency of travel, where you ll be traveling, name of country and locale and length of travel. 8. Have you engaged in, or do you intend to engage in any sports, such as powered vehicle racing, ballooning, hang gliding, scuba diving, sky diving, mountain climbing, cave exploring, rodeos, bungee jumping, or any record events?... Yes No If yes, complete Avocation Questionnaire. 9. Have you ever been convicted of a crime or are you currently on probation?... Yes No If yes, provide the type of conviction(s) and date(s) of probation, name of county and state where convicted, and date(s) of convictions. 10. Has anyone offered you free insurance, a cash payment or some other promised benefit as an incentive to apply for this life insurance policy?... Yes No 11. Have you been involved in any discussions regarding selling this life insurance policy?... Yes No 12. Have you had or have you discussed having an evaluation to determine your life expectancy by any person or entity, other than Allianz Life Insurance Company of North America or its representative, in the last one year period or the next one year period?... Yes No If yes, please explain. 13. Will any portion of the premium for this insurance be financed?... Yes No a. If no, what source of funds will be used to pay for this policy? (for example; income savings, investments, or mortgage) b. Will any portion of the premium for this insurance be paid for by someone else?... Yes No If yes, by whom? c. If yes, are you obligated to repay the loan?... Yes No d. What is the plan to repay the loan? e. Will you be able to pay the premiums on the policy if you were not able to renew the loan at some time in the future?... Yes No 14. Have you discussed changing ownership or beneficiaries once this policy is issued?... Yes No If yes, please provide the changes that will be made. 15. Do you believe this life insurance policy that you are applying for will meet your insurance needs and financial objectives?... Yes No 16. Did the producer discuss with you your current life insurance policies and other assets prior to your decision to purchase this life insurance policy?... Yes No 17. Do you feel you have sufficient liquid assets available for living expenses and emergencies in addition to the money allocated to pay the life insurance premiums?... Yes No 18. Do you engage in regular exercise?... Yes No If yes, please provide type of exercise, how often you exercise, and how long you exercise. Please provide details to questions 1-18 in the space below Question Details NB VA Page 5 of 9 (3/2017)

6 11. Medical Questions - Proposed Other Insured Rider/Second Insured Name of your personal physician Address of your personal physician Phone number of your personal physician Reason consulted Date of last visit Diagnosis made treatment prescribed Height in feet and inches: Feet, Inches Weight in Pounds: lbs. 1. Has your weight changed 10 pounds or more (weight loss or gain) in the past 12 months?... Yes No 2. Do you have a physical deformity or defect?... Yes No 3. Within the past 10 years, have you received medical advice or has treatment been recommended or received for: a. Any abnormality or disease of the brain or nervous system, including depression, psychiatric or mental disorder, seizures, stroke or Transient Ischemic Attack (TIA), Parkinson s disease, Multiple Sclerosis, Amyotrophic Lateral Sclerosis (ALS), Muscular Dystrophy, dizziness, numbness, or weakness?... Yes No b. Any disease or abnormality of the heart or blood and blood vessels including high blood pressure, heart attack or coronary artery disease, congestive heart failure, irregular heartbeat, peripheral vascular disease, anemia, or other blood disorder?... Yes No c. Any disease or abnormality of the lungs or respiratory system including asthma, emphysema or chronic obstructive pulmonary disease (COPD), or sleep apnea?... Yes No d. Any disease or abnormality of the liver, pancreas, rectum or intestines, stomach or esophagus including hepatitis or cirrhosis, Barrett s esophagus, Crohn s or ulcerative colitis?... Yes No e. Any disease or abnormality of the kidneys or urinary system, breasts, prostate, genitals, or reproductive system including sexually transmitted diseases other than Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?... Yes No f. Diabetes or any other disease or abnormality of the thyroid or other glands?... Yes No g. Any disease or abnormality of the joints, muscle, or bones including arthritis, fibromyalgia, fatigue, systemic lupus (SLE), back trouble, osteoporosis, or joint replacement?... Yes No h. Any disease or abnormality of the eyes, ears, nose, throat or skin?... Yes No i. Any disease or abnormality of the immune system (other than HIV or AIDS)?... Yes No 4. Have you ever received medical advice or has treatment been recommended or received for any cancer, tumor, or other abnormal growth?... Yes No 5. Within the last 12 months, have you ever noticed any lump in your breast, lymph nodes, or elsewhere on your body?... Yes No 6. Have you ever received treatment for or been diagnosed by a member of the medical profession for positive HIV status, Acquired Immune Deficiency Syndrome (AIDS), or AIDS Related Complex (ARC)?... Yes No 7. Within the past 10 years, have you used marijuana, cocaine, heroin, amphetamines, barbiturates, morphine, Lysergic Acid Diethylamide (LSD), Phencyclidine (PCP), or any other hallucinogenic or narcotic drug or controlled substance?... Yes No 8. Within the past 10 years, have you been advised to seek or had treatment for alcohol use or drug dependency?... Yes No If yes, include the date(s) of treatment, type of treatment and name of the facility if applicable. 9. Have you been prescribed or are you presently taking medication including prescription, nonprescription, or alternative remedies (e.g. holistic or herbal)?... Yes No 10. Within the past 5 years, other than above, have you consulted, or had any checkup or physical consultation by a medical professional, had any diagnostic testing, been a patient in a hospital, or clinic, or have you had or been advised to have surgery?... Yes No 11. In the past 10 years, have you been treated or diagnosed with any other medical condition(s) not previously disclosed?... Yes No 12. Within the last 5 years, have you ever or are you currently receiving benefits from a disability or long term care insurance plan, state or county assistance program, Medicaid, state or federal disability program or worker s compensation?... Yes No 13. Within the past 5 years, have you refused recommended surgery or treatment?... Yes No NB VA Page 6 of 9 (3/2017)

7 11. Medical Questions - Proposed Other Insured Rider/Second Insured (continued) 14. Please fill in the box below regarding your family members (mother, father, siblings). Please provide the details if they have been diagnosed with and/or treated for cancer, stroke or aneurysm, diabetes, heart disease, surgery, or failure, including coronary bypass, or neurodegenerative disorder. Relationship to Applicant Mother Current age, if living Details to any of the conditions named above including type of cancer, if applicable Age at diagnosis, if applicable Age at death, if applicable Father Brother(s) Sister(s) 15. Within the past 12 months, have you ever required or do you currently require assistance or supervision, or are you limited in performing any daily activities such as bathing, dressing, toileting, managing money, using the telephone, driving, eating, mobility, or managing medication?... Yes No 16. Within the past 12 months, have you ever required or do you currently require or use a cane, brace(s), walker, wheelchair or any other medical appliance such as catheter, oxygen equipment, respirator or dialysis machine?... Yes No 17. Within the past 5 years, have you had symptoms of, been diagnosed with, or been treated by a member of the medical profession for incontinence, imbalance or gait disturbance, confusion, dementia, Alzheimer s disease, or memory loss?... Yes No Please provide details to questions 1-17 in the space below Question Date Details or reason Name and address of medical source or facility NB VA Page 7 of 9 (3/2017)

8 12. Certification of Taxpayer Identification Number If you are applying for this product and/or requesting payments as a U.S. Person, the IRS requires you to agree to the following statements. Under penalties of perjury, I certify that: 1. The Taxpayer Identification Number shown on this form is correct or I am waiting for a number to be issued to me. 2. I am not subject to backup withholding because: a. I am exempt from backup withholding, or b. I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or c. The IRS has notified me that I am no longer subject to backup withholding. 3. I am a U.S. person, and 4. The Foreign Account Tax Compliance Act (FATCA) code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Check here if the IRS has notified you that you are currently subject to backup withholding because you failed to report interest and dividends on your tax return. 13. Acknowledgement and Signatures Each of the undersigned declares, understands and agrees that: The statements and answers contained in the application, which includes any amendments and supplements to the application, are complete and true to the best of each proposed insured s and proposed policy owner s knowledge and belief. The statements and answers contained in the application shall be considered representations and not warranties and shall form the basis of any life insurance contract that may be issued. A copy of the application shall be considered a part of the policy. The proposed policy owner, if not a proposed insured, adopts and ratifies said statements and answers contained in the application. Coverage under any policy approved or issued by Allianz Life Insurance Company of North America (Allianz) as a result of the application shall be considered effective and in force only when, during the proposed insured s lifetime and continued insurability (a) a policy is issued, delivered, received and accepted by the proposed policy owner; (b) the first full premium has been received by Allianz Life Insurance Company of North America; and (c) all answers material to the risk are still true and complete to the best of the proposed owner s and proposed insured s knowledge. Only an officer of the Company can make, modify, alter or discharge policies or waive any of the Company s rights or requirements. The MIB, Inc. Investigative Consumer Report Notice of Disclosure has been received by me. ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT THEY ARE FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE VIOLATED THE STATE LAW. CAUTION: If the answers on the application are incorrect or untrue, Allianz Life Insurance Company of North America may have the right to deny benefits or rescind the policy, subject to the Incontestability provision of the policy. Signed at: City State Proposed Other/Second Insured Signature: Proposed Policy Owner s Signature: (if other than proposed primary/first insured) Proposed Joint Policy Owner s Signature: (if other than proposed primary/first insured) Date: Date: Date: NB VA Page 8 of 9 (3/2017)

9 14. Producer Certification and Signature - To be answered by a licensed Producer By signing below, the Producer certifies to the following: I certify that the statements of the proposed policy owner(s) and insured(s) have been correctly recorded in this Supplemental Application. I certify that the statements of the Owner have been correctly recorded. Yes No Does the proposed insured(s) have an existing life insurance policy or an existing annuity contract? Yes No Will this life insurance replace or change an existing life insurance policy or annuity contract? Writing Producer s Signature: Date: Producer Name (please print) Phone Number Make all checks payable to Allianz Life Insurance Company of North America. Do not make checks payable to an agency, broker, agent, financial professional, or leave payee blank. Please submit the form using one of the options below: completed forms to: lifeinsurance@send.allianzlife.com OR Web Upload: You can upload your signed and completed form(s) by logging into your account at Allianzlife.com OR Mail: Regular Mail Overnight Mail Allianz Life Insurance Company of North America Allianz Life Insurance Company of North America PO Box Golden Hills Drive Minneapolis, MN Minneapolis, MN OR Fax: Any questions? Call us at NB VA Page 9 of 9 (3/2017)