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Rule 20:06:06:0B Sample Application Form. CHAPTER 20:06:21

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF LABOR AND REGULATION

 

DIVISION OF INSURANCE

 

 

 

 

SAMPLE APPLICATION FORM

 

 

Chapter 20:06:06

 

APPENDIX B

 

SEE: § 20:06:06:11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          Source: 32 SDR 203, effective June 5, 2006.

 

 

 

 


APPENDIX B

 

Insured Debtor

John Doe                                                                               Box 555                                                                        Anywhere, USA, 55555

Date of Birth                           

Age           

Certificate Number   

Joint Insured Debtor

 

 

 

Creditor (Beneficiary)   (Name and Address)

ABC Bank                                                                                                                          555 AVENUE                                                                                                           Anywhere, USA 55555            

Creditors Insurance Account No

Assignee                                                          (Name and Address)

Monthly Payment

Annual Simple Interest Rate

Second Beneficiary

Relationship

EFFECTIVE DATE

EXPIRY DATE

Days to 1st Payment

COVERAGES

INITIAL AMOUNT OF INSURANCE

PREMIUMS

TERM IN MONTHS

□     Gross                  or

□     NET

□     W. Dism

□   W/O Dism

□     Decreasing Term

 

□     Periodic Decreasing Term

 $   5,400.00

 $                 -  

36

□     Jt. Decreasing Term

 

□     Jt. Periodic Decreasing Term

 

 

 

□     Level Term

 

□     Jt. Level Term

 

 $ 11,197.00

 $                 -  

36

35

Payments of  $

$150.00

 

 $   5,400.00

 $                 -  

36

 

Final Payment of $

$11,347.51

 

 [$150.00                          Monthly Disability Benefit]

$                  -  

PREMIUM                                    ←TOTAL

□     Disability Coverage    (Insured Debtor Only)

 

 

 

 

WAITING PERIOD     ELIMINATION PERIOD

 

 

□     7 Days

Retrospective

0 Days

 

□     14 Days

Retroactive

0 Days

Maximum Monthly Disability (per debtor)                                                                                                                                                                                                                                     

Maximum Monthly Disability (per debtor)

Maximum Term

 Maximum Issue Age 65 Inclusive

          □     30 Days

Retroactive

0 Days

□     14 Days

Non-Retro

14 Days

          □     30 Days

Non-Retro

30 Days

 

 

 

$1000.00 (Ages 18-65)

$100,000.00 Ages 18-65)

120 Months

 

 

 

 

 

 

 

 

 

 

 

DEATH CLAIM STATEMENT- INSTRUCTIONS: Creditor Policyholder should complete the statement below and return with the following documents: 1. Certified copy of the Death Certificate showing cause of death; 2. Copy of the conditional sales contract or note covered by the Insurance; 3. Copy of the Policy or Certificate Issued to the deceased. This completed form, together with the documents specified above, should be sent to:

 

 

ABC ASSURANCE COMPANY     Insurance Division, 555 Boulevard, Anywhere, USA, 55555-555

 

 

 

 

 

 

 

 

 

1. Name of Insured

 

2. Certificate No. (or individual Policy No.)

Date of Loan

 

for Term of

Mos.

 

3…………………………………

Original Amount Insured

…………………………….

 $                      -  

 

 

 

 

4…………………………………

Less Amount Paid

…………………………….

 $                      -  

 

 

 

To comply with certain State Laws, our payoff to a creditor may be for the net amount due (Gross amount less unearned interest and/or advance payments). Please advise us of this amount. Any remaining balance is payable to the second beneficiary if named, otherwise to the Debtors Estate.

5…………………………………

Less Unearned Interest

……………….…………

 $                      -  

6…………………………………

Less Unearned A & H Premium                                              (Life Premium Earned)

……………………………

 $                      -  

7…………………………………

Balance Due

……………………………

 $                      -  

8………………………………….

Number of Monthly Payments in Default at Death

 

 

 

 

 

9………………………………….

Creditor Policyholder's Name

"Insurance Account No."

 

Street Address

City

State

Zip Code

 

 

I hereby certify that the above answers are complete and true, and the balance due is the amount in line 7.

 

Date:

By:

Title:

 

 

 

 

 

 

 

 

 

PREMIUM REFUND RECEIPT SCHEDULE

Send to: P.O. Box 555 Anywhere, USA 55555-555

 

 

MO.

DAY

YEAR

 

LIFE

DISABILITY

TOTAL

DATE OF CANCELLATION

 

 

 

PERCENT UNEARNED

%

%

 

 

 

 

 

 

 

 

 

POLICY CERTIFICATE WAS IN FORCE

 

MONTHS

 

AMOUNT OF REFUND

%

%

 

I understand, hereby request cancellation of the above numbered certificate or policy as of 12:00 noon, Standard Time, as of the date of cancellation shown above. I hereby acknowledge receipt of the amount of refund shown above as a full refund of the unearned portion of the premium and hereby release ABC Company from all further liability under said certificate (s) or policy(ies)) as the case may be

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

AGENT OR WITNESS

 

 

SIGNATURE OF INSURED

 

 

 

 

 

 

 

 

 

Name of Creditor

Address

 

 


 


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