PRESIDENTIAL LIFE INSURANCE COMPANY

Transcription

1 The following information is required with every new application submitted for the GBL product. GBL Customer Information Transmittal General agent: (Print name) GA#: Writing agent: (Print name) WA# Insured s Information Name: (print) Social Security # Owner Information Name: (print) Social Security # Relationship of All Beneficiaries MAIL IN THE FOLLOWING ITEMS: State of Residence Application (Properly completed and/or signed). If required. addendum RPL-NAIC(02) (See Special State Forms list.) If the answer to section A is yes, even if no replacement is taking place, RPL-NAIC(01) MUST also be completed & signed. If a replacement is involved, Section B is to be completed. Answer residence application question #8 correctly. (Age 40 through 64 = 3 years, except WV = 2 years, Age 65 or older = 2 years) Modal premium prior to issue. Monthly mode is ONLY available thru Direct Debit. You must remit one month premium as well as a Direct Debit form. Full mode MUST be submitted for Quarterly, Semi-Annual or Annual modes. DDA Bank Draft form and copy of void check. If Replacing other insurance. State of Residence Replacement Form. (See Special State Forms list) If Pennsylvania Application Appendix A Disclosure Statement Delivery Receipt given to the applicant no later than at the time that the application was signed by the applicant. Application (8/00) PA Part I, a non-med Part II. GBL application 17.7(3/00)(PA) and premium are submitted. IMPORTANT: Coverage becomes effective when application is received in the Presidential Home Office in good order. AGENT SECTION:. Already Appointed Agent Copy of current license on file with Presidential. Memo225_AML-Policy signed and dated with name clearly printed Proof of Anti-money laundering (AML) certification on file with Presidential. or indicate if completed through LIMRA? Yes New Agent License Information sheet IRS form w-9 2 copies of WA agreement with correct compensation level indicated. Signed and dated with name printed clearly Copy of current personal and/or corporate license Applicable state appointment fee Memo225_AML-Policy signed and dated with name clearly printed Proof of Anti-money laundering (AML) certification or indicate if completed through LIMRA? Yes Graphics Dept./ GBLcustomerInfoTransmittal_

2 APPLICATION TO PRESIDENTIAL LIFE INSURANCE COMPANY THIS APPLICATION IS TO BE ATTACHED TO AND MADE A PART OF THE POLICY Proposed Insured Address Print Name in Full Street City State Zip 1. of Birth Age Nearest Birthday Sex Month Day Year Male Female 2. Plan of Insurance -- Graded Benefit Life Policy Amount of Insurance $ 3. Beneficiary - Print Full Name and Relationship Primary Contingent Unless otherwise specified under remarks the interest of beneficiaries and owners are to be governed by the company's standard policy provisions. 4. Applicant/Owner if other than Proposed Insured Address Street City State Zip 5. Premiums are to be paid Annually Semi Annually Quarterly ABC Amount paid with this application $ 6. Is there any other life insurance in force on a guaranteed issue basis? Yes No (If "Yes," list name of insurance company and amount of insurance.) 7. Does Applicant intend to drop or change any existing individual life insurance policy or annuity on your life in favor of the insurance now applied for? Yes No (If "Yes," list, by insurance company & policy number, the policy or policies to be dropped or changed.) 8. Remarks Signed at this day of 20 City and State Proposed Insured Sign name in full Applicant/Owner If other than the Proposed Insured-Sign name in full Licensed Agent Sign name in full AGENT'S CERTIFICATE Is this insurance intended to replace other insurance? I HEREBY CERTIFY that I personally solicited and secured this application and except as indicated above, no one else is to have any share in the agent's commission thereon. Agent's Signature Code No (3/00)(OK) Yes No This application was solicited and written within my territory by a duly licensed agent of my agency. GA s Signature Code No.

3 NOTICE TO APPLICANTS REGARDING REPLACEMENT OF LIFE INSURANCE OR AN ANNUITY. THIS NOTICE IS FOR YOUR BENEFIT AND IS REQUIRED BY LAW. 1. If you are urged to purchase life insurance and to, lapse, or in any other way change the status of existing life insurance, the agent is required to give you this notice. 2. It may not be advantageous to drop or change existing life insurance in favor of new life insurance, whether issued by the same or a different insurance company. Some of the disadvantages are: a. The amount of the annual premium under an existing policy may be lower than that under a new policy having the same or similar benefits. b. Generally, the initial costs of life insurance policies are charged against the cash value increases in the earlier policy years, the replacement of an old policy could result in the policyholder sustaining the burden of these costs twice. c. The incontestable and suicide clauses begin anew in a new policy. This could result in a claim under a new policy being denied by the company which would have been paid under the old policy. d. Existing policies may have more favorable provisions than new policies in such areas as settlement options and disability benefits. e. An existing policy may have a reserve value in addition to any cash value which may be of some benefit to the insured. f. The insurance company carrying your current insurance policy can often make a desired change on terms which would be more favorable than if existing insurance is replaced with new insurance. 3. It may not be advantageous to change an existing policy to reduce paid-up or extended term insurance or to borrow against its loan value beyond your expected ability or intention to repay in order to obtain funds for premiums on a new policy. 4. There may be a situation in which a replacement policy is advantageous. You may want to receive the comments of the present insurance company before deciding this important financial matter. I hereby acknowledge that I received the above "Notice to Applicants Regarding Replacement of Life Insurance or an Annuity" before I signed the application for the proposed new insurance. Signature of Applicant Original to Applicant Copy to Home Office Copy to Agent RPL-OK(1) To be used with life & annuity replacements

4 DEFINITIONS Premiums: Premiums are the payments you make on the life insurance or annuity contract. They are unlike deposits in a savings or investment program because if you drop the policy you might get back less than you paid in. Surrender : This is the amount of money you can get if you your life insurance policy or annuity. If there is a policy loan, the cash value is the difference between the cash value printed in the policy and loan value. Not all policies have cash values. Lapse: A life insurance policy may lapse when you do not pay the premiums within the grace period. If your policy had a cash value, the insurer might change your policy to as much extended term insurance or paid-up insurance as the cash value will buy. Sometimes the policy lets the insurer borrow from the cash value to pay the premiums. Surrender: You a life insurance policy when you either let it lapse or tell the company you want to drop it. If a policy has a cash value, you can receive such value in cash if you return the policy to the company with a written request. Place on Extended Term: This means you use your cash value to change your insurance to term insurance with the same insurer. In this case, the death benefit will be the same as before but you will only be covered for a specified period of time. Borrow Policy Loan s: If your life insurance policy has a cash value, you can usually borrow all or part of said amount from the insurer. Interest will be charged according to the terms of the policy, and if the loan and unpaid interest ever exceeds the cash value the policy will be terminated. If you die, the amount of the loan and any unpaid interest due will be subtracted from the death benefits. Evidence of Insurability: This means proof that you are an acceptable risk. You have to meet the standards of the insurer regarding age, health, occupation, and such other standards as the insurer feels necessary to be eligible for coverage. Incontestable Clause: This says that after one (1) or two (2) years, according to the provisions of the contract, the insurer shall not resist a claim because you made a false or incomplete statement when you applied for the policy. During the first two (2) years if there are false or incomplete answers on the application and the insurer discovers them, the insurer can deny a claim as if the policy has never existed. Suicide Clause: This says that if you commit suicide after being insured for less than two (2) years, your beneficiaries will receive only a refund of the premiums that were paid. RPL-OK(01)

5 STATEMENT BY APPLICANT REGARDING NOTIFICATION OF REPLACEMENT TO THE REPLACED INSURER I have read the "NOTICE TO APPLICANTS REGARDING REPLACEMENT OF LIFE INSURANCE OR AN ANNUITY" which was furnished to me by the agent taking the application for this policy. (Applicant: Please sign ONE of the following statements.) 1. Please notify my present insurer(s) regarding this transaction. Signature of Applicant 2. Please do not notify my present insurer(s) regarding this transaction. Signature of Applicant The signature of the applicant shall be that of the insured unless someone other than the insured is the owner of the policy. If someone other than the insured is the owner of the policy, the owner must sign. If the insured is under eighteen (18) years of age, the parent is deemed to be the owner of the policy. Certification by the agent: I hereby certify that nothing was said or done during the sales presentation to influence the decision of the applicant regarding this statement. Signature of Agent Insurance Agency or Agent License Number RPL-OK(2) To be used with life & annuity replacements

6 DIRECT DEBIT AUTHORIZATION I hereby authorize Presidential Life Insurance Company, ID Number to initiate debit entries from the account named below to pay premiums on the policy number below. Presidential Life Insurance Company is also authorized to initiate, if necessary, adjustments to the account for any debit or credit entries made by the company in error. POLICY # INSURED BANK NAME BANK ADDRESS STREET CITY STATE ZIP TRANSIT/ABA # ACCOUNT # Select one: Checking Savings of Monthly Withdrawal (1 st thru 28 th ) NAME(s) on account This authority is to remain in full force and effect until Presidential Life receives written notice of its termination signed by the account holder(s) in such time and in such manner as to afford the company and the depository a reasonable opportunity to act on it. Signature of account holder Signature of joint account holder (if applicable) PLEASE ATTACH A VOIDED CHECK OR A DEPOSIT TICKET WITH A MICROENCODED ACCOUNT NUMBER PLEASE VERIFY ALL ACCOUNT INFORMATION WITH YOUR BANK PRESIDENTIAL LIFE INSURANCE COMPANY OR PRES LIF 69 LYDECKER STREET, DDA Rev 8/07

7 MALE Issue Age GBL_PrelimInfo-Receipt_ PRESIDENTIAL LIFE INSURANCE COMPANY IN TEXAS DOING BUSINESS AS ROCKLAND LIFE INSURANCE COMPANY 69 Lydecker Street, Nyack, New York Home Office or PRELIMINARY INFORMATION The following information must be filled in by Agents or Brokers and left with the Client. Generic Name: Graded Benefit Life. Face Amount: $ : Monthly Premium: $ X 12 = Annual: $ Name, Address and Phone of Agent or Broker: GRADED BENEFIT LIFE When the policy is issued, a complete policy summary, including cost data, based on the benefits and premiums of the policy as issued, will be furnished. Following the receipt of the policy and policy summary, there will be a period of not less than ten days within which the applicant may return the policy for an unconditional refund of the premiums paid. The effective annual loan interest rate is 7.4% payable in advance PREMIUM RECEIPT Received from the sum of $ in connection with this application for life insurance to Presidential Life Insurance Company of New York. Signature of Agent or Broker MAKE CHECK OR MONEY ORDER PAYABLE TO PRESIDENTIAL LIFE INSURANCE COMPANY. DO NOT MAKE CHECK OR MONEY ORDER PAYABLE TO AGENT/BROKER OR LEAVE THE PAYEE BLANK. Any check or money order given in payment must be honored on the first presentation for payment. If you do not hear from the Company regarding the proposed insurance within 60 days, notify the Company at its home office in Nyack, New York. Give the name of the agent/broker, date and amount paid. Coverage becomes effective when application is received in the Presidential Home office in good order. FEMALE Issue Age