Power Of Attorney printable pdf download

Power of Attorney

Amendment to application regarding the use of a Power of Attorney (POA)

AAFMAA Number (if known)

1. GRANTOR (Person who signed POA)

Grantor Name (Last, First MI)

Date POA Signed (mm/dd/yyyy)

2. AGENT (Person granted authority by POA)

Agent Name (Last, First MI)

Date AAFMAA Application Signed (mm/dd/yyyy)

3. SIGNATURE

I hereby confirm the following statements:

• I have full knowledge to be able to truthfully and completely answer the medical questions contained in the above

submitted application.

• I understand the answers provided by me on this application will be held to the same standards and accountability

as if the Grantor had completed such application and that AAFMAA will rely on such answers in determining whether

to issue a life insurance policy.

Any misrepresentation or omission of medical or other information, whether

intentional or not, may cause the policy to be rescinded under the two year contestability clause and to be deemed

null and void.

• I understand AAFMAA requires the insured to be the owner of the Certificate when the application is completed

under a Power of Attorney. I am not listed, nor did I sign, as owner of the above reference application.

The above statements are complete and true. I agree that this Amendment to Application is a part of any policy issued

on the basis of the application. I acknowledge that a copy of this Amendment to Application has been attached to any

policy issued pursuant thereto.

Agent Signature

Date Signed (mm/dd/yyyy)

Instructions for Applications submitted using a Power of Attorney (POA)

1. The POA must allow for the ability to obtain insurance.

2. A copy of the POA must be submitted with the application.

3. This form must be completed and submitted with the application.

4. The Attorney-in-Fact must provide a copy of their identification as required in Section 1 of the Application Instructions.

5. All business transacted pursuant to your POA should follow the instructions for signing documents as stated in your

POA. In the absence of specific instructions, all business transacted with AAFMAA should contain Grantors name,

followed by Attorney’s name, followed by the designation, “Attorney-in-Fact.”

EXAMPLE: Kathy Smith (Attorney) has been granted a POA by her husband John Smith (Grantor). In the “Signature

of Insured” box, Kathy Smith signs John Smith, followed by Kathy Smith, followed by Attorney in Fact. “John Smith,

by Kathy Smith, attorney-in-fact”

05/2013

American Armed Forces Mutual Aid Association • 1856 Old Reston Ave, Ste 200, Reston, VA 20190 • 1-800-522-5221 •

Power Of Attorney