Loan Information - Disability Insurance Form

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Loan Information
Disability Insurance
IDENTIFICATION
Name of the Insured:__________________________________________________________________
Policy No.: ______________________________
INFORMATION ON THE LOAN
Type of loan
Mortgage loan (provide a copy of the mortgage statement)
Mortgage line of credit (provide loan contract)
Loan No.: _______________________________________________
Amount of the payments: $____________ . ______
Frequency of payments:
weekly
every 2 weeks
bi-monthly
monthly
Name of the creditor: ______________________________________________________________________________________________
Address of the creditor:____________________________________________________________________________________________
Term of the loan: _______________________
months
year(s) Amortization period, in years:
20
25
30
other _________
Is this loan covered by another insurer:
yes
no
If yes, please specify: Name of the insurer:_________________________________________ Insurance policy No.: _________________
Type of loan
Mortgage loan (provide a copy of the mortgage statement)
Mortgage line of credit (provide loan contract)
Loan No.: _______________________________________________
Amount of the payments: $____________ . ______
Frequency of payments:
weekly
every 2 weeks
bi-monthly
monthly
Name of the creditor: ______________________________________________________________________________________________
Address of the creditor:____________________________________________________________________________________________
Term of the loan: _______________________
months
year(s) Amortization period, in years:
20
25
30
other _________
Is this loan covered by another insurer:
yes
no
If yes, please specify: Name of the insurer:_________________________________________ Insurance policy No.: _________________
Type of loan
Mortgage loan (provide a copy of the mortgage statement)
Mortgage line of credit (provide loan contract)
Loan No.: _______________________________________________
Amount of the payments: $____________ . ______
Frequency of payments:
weekly
every 2 weeks
bi-monthly
monthly
Name of the creditor: ______________________________________________________________________________________________
Address of the creditor:____________________________________________________________________________________________
Term of the loan: _______________________
months
year(s) Amortization period, in years:
20
25
30
other _________
Is this loan covered by another insurer:
yes
no
If yes, please specify: Name of the insurer:_________________________________________ Insurance policy No.: _________________
DECLARATION
I declare that all information given above is, to my knowledge, true, current and complete.
_____________________________________________________________________________
____________________________
day/month/year
Signature of the Insured
Date
Please read carefully the IMPORTANT NOTICE on the back of this document.
01QRI0053A (01-13)

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