Fillable Insurance Enrollment Form (Page 2 of 3) in pdf

SECTION 5: ELIGIBILITY INFORMATION – Required for Guaranteed Issue and all levels of underwriting

Proposed

Your

Insured

Spouse

1. Within the past 12 months, have you used any tobacco products (cigarettes, cigars, snuff,

Yes  No 

dip, chew, pipe) and/or any nicotine delivery system?

Yes  No 

2. Are you actively working?

Yes  No 

If “No”, are you disabled or unable to work?

Yes  No 

3. Is your spouse (if applying for coverage) disabled or unable to work?

REPLACEMENT SECTION - COMPLETE REPLACEMENT FORM IF QUESTION 4 OR 5 IS YES.

4. Does the Proposed Insured have any existing life coverage? If yes, provide details below and complete

Yes  No 

form if applicable in your state.

5. Will any life insurance or annuities with this or any other company be replaced or changed if the coverage

Yes  No 

applied for is issued? If yes, check appropriate box of policy being replaced, modified or discontinued and

complete form if applicable in your state.

Check yes if

Insurance Company Name

Amount of

Insured’s Name

Policy Number

policy

and Address

Coverage

replaced

Yes  No 

AGREEMENT SECTION

THE PROPOSED INSURED AGREES AS FOLLOWS:

Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense

and subject to penalties under state law. I confirm I have read and understand the Fraud Statement attached. I have read

the application and the answers and statements above are true and complete to the best of my knowledge and belief. I

understand that this application will not be binding upon Colonial Life & Accident Insurance Company (Colonial Life) until

both: 1) the policy or certificate is issued; and 2) the first premium due is paid while the Proposed Insured is alive. Items 1

and 2 must occur while any conditions affecting insurability are the same as described. I understand that any material

misrepresentation may result in claim denial or rescission of coverage for two years after the effective date of coverage. If

coverage is rescinded, Colonial Life’s only obligation will be to refund all premiums paid. I understand that the statements

and answers in this application are the basis for any policy or certificate issued by Colonial Life, and no information about

me will be considered to have been given to Colonial Life unless it is stated in the application.

I certify under penalties of perjury that the Social Security number shown on this form is my correct TAXPAYER

IDENTIFICATION NUMBER.

If applicable, I have received and read a copy of the Notice of Insurance Information Practices.

Signed at: City_________________________________ State ______ Date _________________________________

mm/dd/yyyy

(x)_____________________________________________________________________________

Signature of Proposed Insured

AGENT SECTION

I have explained to the Proposed Insured all exceptions and limitations pertaining to the coverage applied for. I hereby certify

that I have truthfully and accurately recorded on this application the information supplied by the Proposed Insured. I further

certify that I know nothing affecting the insurability of the Proposed Insured, which is not fully set forth in this application. I

further certify that I am a licensed agent in the state where this application is being taken. I understand that I do not have

Colonial Life’s authorization to accept risk, pass on insurability, or make, void, waive or change any conditions or provisions

of the application, policy or receipt, as applicable.

Date ___________________________________

(x)____________________________________________________

mm/dd/yyyy

Signature of Licensed Agent (if applicable)

Agent Name_______________________________________ License No.____________________ Code No.__________

GTL - EnrollP - NC

80162

Insurance Enrollment Form Page 2

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