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

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF LABOR AND REGULATION

 

DIVISION OF INSURANCE

 

 

 

 

SAMPLE APPLICATION FORM

 

 

Chapter 20:06:06

 

APPENDIX A

 

SEE: § 20:06:06:11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 


APPENDIX A

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

 $        28,615.00

 $              -  

59

□    Jt. Decreasing Term

 

□    Jt. Periodic Decreasing Term

 

 

 

□    Level Term

 

□    Jt. Level Term

 

 $        22,352.47

 $              -  

60

59

Payments of  $

$485.00

 

 $        28,615.00

 $              -  

59

 

Final Payment of $

$22,352.47

 

 [$485.00                          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

 

 

 

 

 

 

 

 

 

 

Application for Insurance

 

 

 

 

 

 

 

 

 

 

 

 

ABC ASSURANCE COMPANY

 

(Called We)

Anywhere, USA 55555-5555

 

 

 

 

 

 

 

I am indebted to the above named Creditor for the above sum and for the security of payment of said debt. I hereby apply for credit insurance covering the amount of said debt as indicated above

 

I represent that the answers on this application are true and complete to the best of my knowledge and belief. They are the basis on which insurance requested by me may be issued.

 

Insured

Debtor

 

 

 

Joint Insured

Debtor

Yes

No

 

 

 

Yes

No

1. Are you under age 66?

2. Are you in good health as far as you know and believe?

3. Are you actively and gainfully employed for wage or profit on a full time basis

N/A

 

 

 

 

 

 

 

4. During the past 5 years have you been treated for, or been told you had, any of the following conditions (Please Circle) High Blood Pressure; Heart Disease; Cancer or Tumor; Diabetes; Stroke; Disease of Liver or Kidney; Alcoholism; Drug Addiction; any Brain, Nervous System or Mental/Neurological Disorder; Acquired Immune Deficiency Syndrome (AIDS).

I understand that if the aforesaid representations are false and untrue, the Insurance Company's Liability shall be limited to the return of the premium paid for said coverage (subject to the 2-year incontestability provision).

I further understand that the insurance prepaid for is not compulsory, nor a condition precedent to any loan or credit transaction. I certify that I have been given the option to purchase such credit insurance from any insurer or agent of my choice. I freely chose the insurer and agent to whom this application is made. I declare that I have read or had read to me this statement before signing.

 

 

 

 

 

 

 

Date

Signature of Insured Debtor

 

 

 

 

 

 

 

Witness

Signature of Joint Insured Debtor

 

 

 

 

 

 

 

Upon Acceptance by the Insurer, the insurance shall become effective as of the effective date shown above.

 

 


 


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