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Life Insurance

1.

 PERSONAL INFORMATION ABOUT PROPOSED INSURED

Name of Proposed Insured:
(First, Middle, Last)

Date of Birth

Age

Home Address:

Birthplace
(State, Country)

Social Security No.

City:

State:

Zip:

Drivers License Number:

State issued

Occupation:

2.

  COVERERAGE APPLIED FOR

PLAN OF INSURED:

Face or specified amount:

Benefit:

Waiver Due
To disability

 

Spouse Rider

Other

 

Accidental
Death Ben$

Child ryder

Other

Premium
Mode:

Annual

Semi-Annual

Quarterly

Monthly PAC

Other

UL PLANS ONLY:

Planned Premium$

Death Benefit Option:

Increasing

Level
Billing Address:
Second Address Billing Notice For Lapse For Nonpayment of Premium:

Yes-complete Form
L-2723(99)

 NO

3.

 OWNER INFORMATION
Name of owner (complete only if other then Proposed Insured)
(If trust, provided Name and date of trust)

Home Address:
Relation to
Proposed Insured:		 Owner's Soc.Sec.
or Tax ID#:

4.

 BENEFICIARY INFORMATION

Beneficiary(ies) Full Name(s)(If Trust,
provide Name and Date of Trust)
Primary  

Age

Relation to proposed Insured

Trust Tax ID#

Contingent

Unless otherwise stated, proceeds will be paid in equal shares when more then one beneficiary is listed.
If no designated beneficiary lives to receive payment, proceeds will be paid according to the terms of the contract.

5.

 REPLACEMENT
Will the coverage applied for replace or change any existing or applied for life insurance or annuity?.... Yes No
If yes, provide company name, amount of coverage, issue date, and type of coverage below, AND complete applicable Replacement Form(s)

Company

Amount

Issue Date

Type of Coverage
$

Term

 Permanent Group
$ Term Permanent Group
$ Term Permanent Group

6.

 PRELIMINARY HEALTH QUESTION
Within the  past 10 years, have you been diagnosed or treated by a medical professional for any of the following:
heart disease; cancer; brain or mental disease; or alcohol or drug abuse?.....
Yes No

7.

 TELEPHONE INTERVIEW INFORMATION
An authorized interview may call to obtain addition information required to complete this application.
Check the most convenient place and time to call:

Home  

Business
8:00am
10:00 am		 10:00 am
12:00 pm		 12:00 pm
2:00 pm		 2:00 pm
5:00 pm		 5:00 pm
8:00 pm		 After
8:00 pm		 Any Time

8.

   REMARKS/SPECIAL REQUESTS

9.

 ADDITIONAL INSURED/SPOUSE (complete only if coverage applied for)
Name (First,Middle,Last): SexMF Date of Birth:

SS# Birthplace
(State or country)		 Dr Lic # State
Issue:
Note: If applying for Additional Insured/Spouse coverage, also complete a separate Part 1 and Part II application.

10.

 AGREEMENT/AUTHORIZATION TO OBTAIN AND DISCLOSER INFORMATION
The Owner Understands And agrees As Follows:

 STATEMENTS IN THE APPLICATION- All statements in this application are true and complete to the best of my knowledge and belief and were correctly recorded before I signed my name below. Statements in this application, including statements by the Proposed Insured in any medical questionnaire that become a part of this application, will be the basis of any insurance issued.
False statements or misrepresentation in this application may result in loss of coverage under the policy.

EFFECTIVE DATE -Any insurance issued as a result of this application will either: (1) not take effect until the full first premium has been paid and the policy is delivered to and accepted by the Owner during the Proposed Insured's lifetime and while such person is in the stead health described in all parts of the application; or (2) take effect only as specified in the Temporary Insured Agreement if issued.

LIMITATION OF AUTHORITY- No agent, broker, telephone application interviewer, or medically examiner is authorized to determine insurability, modify or waive any terms of this application or waive any of the company's rights or requirements.
Knowledge of any fact not disclosed in this application on the part of any agent, broker, telephone application interviewer, medical examiner, or other person will not be considered knowledge by the Company
PAYMENT OF PREMIUM - (CHECK ONE) This application is C.O.D.;or I have paid$    

with this application in consideration of  a Temporary Insurance Agreement. I have read,
understand, and agree to the terms of the Temporary Insurance agreement.

AUTHORIZED- I authorized: (1) any doctor, hospital, clinic, or other medical or  medically related
facility, insured company, vertical company, vertical broker or provider, or other organization,
institution or person, that has any records or knowledge of me or any named Proposed Insured, to
give the Company, its representatives or reinsure's,, any such data; (2) the company to conduct
a personal telephone interview in connection with my application: an (3) the company to release
any such data to its reinsure's, the medical  information bureau, or as required by law or as provided in the Notice of Information Practices when given a copy of this authorization.
Data released may include results of my medical examination or tests requested by the company.
Data obtained by use of this authorization will be used by the company to determine eligibility
for insurance. This authorization is valid for 30 months from the earlier of: (1) the date signed, or
(2)the policy date. I may revoke this authorization for information not then obtained by notifying
the Company in writing. Such revocation will not be in effective until received by the Company.
I understand that I or any authorized representative will  receive a copy of this authorization upon
request.

I have read and received a copy of the Consumer Protection Notices.

 TAXPAYER ID CERTIFICTION: As Owner of this contract, I certify under penalty of perjury that:(1) the taxpayer identification number shown on this application is correct; and (2) I am not subject to IRS backup withholding.
NOTE: Check this box if you are currently subject to backup withholding. The Internet Revenue Service does not
require your consent to any provision of this document other than the certification.
 

11.

 HOME OFFICE ENDORESMENT(S)

12.

SIGNATURES
Signed at
 


(City, State

 On
 


(Date)

X
 Signature of Proposed Insured


Signature Of Spouse (If coverage applied for)

X
 Signature of Parent/Guardian,
if proposed insured is a minor

  

X
 Signature of Owner,If other than Proposed Insured
(If Owner is corporation,trust,or other entity, include title of signee.)
Signature of witness, If applicable( other than family member): X
To the best of my knowledge and belief,
 the insurance applied for		 is or is likely is not or is not likely to replace or change any existing insurance coverage.
Signature of Licensed Agent X
Licensed Agent's Name
(please print)		 Florida Agent License#

 
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Briarway Insurance Agency, Inc. |14229 S. Dixie Hwy. (U.S. 1) | Miami, Fl 33176| Phone (305)251-5546
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