THE UNITED STATES LIFE Insurance Company
An American General Company
APPLICATION FOR GROUP TERM LIFE INSURANCE

IMPORTANT NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which may be a crime. This does not apply in Virginia.
 
1. Association Name:EAA Group Life PlanGroup Policy #:                                               
 

2. Member's Full Name:
                                                                      
    (first)                     (middle)                      (last)

 

Residence Phone:                                             
Soc. Sec. No.:                                                 


3. Spouse's Full Name:
                                                                      
    (first)                     (middle)                      (last)
 		Soc. Sec. No.:                                                 
 
 

4. Mailing Address:                                                                                                                  
                                         (number)          (street)

                                                                                                                                               
                               (city)                                   (state)                                                       (zip code)

 

5. Beneficiary                                                                    Relationship                                 
  Unless otherwise requested, the member will be the beneficiary of any spouse and children insurance applied for.

 

6. Check Life Insurance Plan(s) desired:

  Life insurance for member?

  Life insurance for spouse?

  Life insurance for children?

 

 

Amount $                               

Amount $                               

Amount $                               

 

7. Complete the following for applicant and spouse and children if applying for insurance:

Age

Date of Birth

Place of Birth

Height

Weight

Sex

Applicant:    /        /

 

ft.        in.lbs.m/f
Spouse:     /        / ft.        in.lbs.m/f
Child:     /        / ft.        in.lbs.m/f
Child:     /        / ft.        in.lbs.m/f
Child:     /        / ft.        in.lbs.m/f
8. Have you or any dependents, if applying, ever had chest pains, heart trouble, liver trouble, high blood pressure, albumin or sugar in your urine, tuberculosis, diabetes, cancer, tumors or ulcers?

Applicant

YesNo

Spouse

YesNo

Child

YesNo

 

9. Have you or your spouse, if applying, during the past 5 years, consulted any physician or other practitioner or been confined or treated in any hospital or similar institution?

Applicant

YesNo

Spouse

YesNo

 

10. Have you or your spouse used tobacco or nicotine in any form during the past 12 months?

Applicant

YesNo

Spouse

YesNo

 

If "YES" to any part of questions 7 and/or 8, give details below. Use a separate sheet of paper if more space is needed for answers.

Question #

Name of Proposed InsuredConditionDate OccurredDurationDegree of RecoveryName & Add. of Dr.'s/hospitals/ clinics consulted
 
 
 
 
 
AUTHORIZATION AND DECLARATION OF EACH PERSON GIVING A STATEMENT OF INSURABILITY
  1. I authorize the sources stated below to give to The United States Life Insurance Company, or any consumer reporting agency acting on its behalf, information about me. Such information will pertain to other insurance coverage and medical care, advice, treatment or supplies for any physical or mental condition. Authorized sources are: any physician or medical professional, any hospital, clinic or other medical care institution, any insurer, the Medical Information Bureau, any consumer reporting agency.
  2. I understand that this information will be used by The United States Life Insurance Company to determine eligibility for insurance.
  3. I understand that I may revoke this authorization at any time. I agree that such revocation will not affect any action which The United States Life Insurance Company has taken in reliance on the authorization. I understand that this authorization will not be valid after 30 months, if not revoked earlier.
  4. I know that I have the right to receive a copy of this authorization, if I request one.
  5. I agree that a photocopy of this authorization is as valid as the original.
  6. To the best of my knowledge and belief, all the statements made above are true and complete.
  7. I understand that my application for group insurance will be accepted or declined on the basis of these statements. Insurance shall take effect only if a certificate is issued based on this application and the first premium is paid in full (a) during the lifetime of all proposed insureds and (b) while there is no change in the insurability and health of all such persons from that stated in this application.

                                      
(date signed)

X                                                                                 
(signature of applicant)

                                      
(date signed)

X                                                                                 
(signature of spouse, if applying for insurance)

 

 For Office Use Only - Eff.                   Ren. Date                   Paid                   CC                   Cert. No.                 
 

Mail this form to:

 

Harvey Watt & Co.
EAA Group Insurance Plans
PO Box 20787, Atlanta Airport
Atlanta, GA 30320
Toll Free: (800) 241-6103

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MIB DISCLOSURE NOTICE: These notices must be detached and retained by the applicant.

Information given in your application may be made available to other insurance companies to which you make application for life or health insurance coverage or to which a claim is submitted. Information regarding your insurability will be treated as confidential except that The United States Life Insurance Company in the city of New York may, however, make a brief report thereon to the Medical Information Bureau, a nonprofit membership organization of life insurance companies which operates an information exchange on behalf of its members. Upon request by another member insurance company to which you have applied for life or health insurance coverage or to which a claim is submitted, the Medical Information Bureau will supply such company with the information it may have in its files. Upon a receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau's file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau's information office is: Post Office Box 105, Essex Station, Boston, Massachusetts, 02112, telephone number (617) 426-3660. The United States Life Insurance Company in the city of New York may also release information in its file to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted.