Fillable Und 68-1 Fl - Resident Alien Supplement Form printable pdf download

Und 68-1 Fl - Resident Alien Supplement Form

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Resident Alien Supplement

(Supplement to Application)

Genworth Life Insurance Company (GLIC) • Genworth Life and Annuity Insurance Company (GLAIC)

700 Main Street • Lynchburg, VA 24504

1. Proposed Insured

Please print all answers

a. Full Name

b. Date of Birth (Mo. Day Yr.)

c. Does the Proposed Insured speak English? If "No," give name of any interpreter and relationship to Proposed Insured. ........................

Yes No

d. Birthplace

e. Current Citizenship

f. Date of Entry to the U.S.A.

g. Kind of Visa:

Permanent (Green Card)

Work

Student

Other (Specify):

h. Visa Symbol

i. Visa Number

j. Visa Expiration Date

k. Have you applied for U.S. citizenship? If "Yes," give status. If "No," give reason. .......................................................................................

Yes No

l. List immediate family members by name, relationship, age and citizenship

Within the U.S.A.

Outside the U.S.A.

m. Education

n. Occupation

o. Name and Address of Employer

p. Date Hired by Employer

q. Specific Occupational Duties

r. Do you own assets or property in or outside the U.S.? If "Yes," specify asset/property and give specific location. ..................................

Yes No

s. Do you plan to travel or reside outside the U.S.? If "Yes," give details below for each country. .................................................................

Yes No

Country

Specific Location

Departure Date Duration

Purpose

I represent that the statements and answers given in the application are true, complete, and correctly recorded to the best of my knowledge and belief. I further

agree that: (1) I will notify the Insurer if any statement or answer given in the application changes prior to policy delivery; and (2) except as provided in the

Temporary Insurance Application and Agreement, if any, insurance will not begin unless all persons proposed for insurance are living and

insurable as set forth in the application at the time a policy is delivered to the Owner and the first modal premium is paid.

Fraud Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Signature of Proposed Insured

Date

UND 68-1 FL

1/2007