Form Frsl-8209-0594 - Preliminary Application For Group Or Blanket Insurance
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1First Reliance Standard
PRELIMINARY APPLICATION FOR GROUP OR BLANKET INSURANCE
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Life Insurance Company
1. Prospective Policyholder:__________________________________________________________________________
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(Exact Legal Name)
2. Federal Employer Identification Number:_____________________________________________________________
3. Complete address: _____________________________________________________________________________
(Street Address)
(City and State)
(County)
(Zip Code)
Executive Correspondent_______________________Title_____________________ Phone____________________
Routine Correspondent_________________________Title_____________________Phone____________________
Mailing Address (If different)_______________________________________________________________________
4. Nature of business: (If Association: purpose, when formed) _____________________________________________
5. The prospective policyholder is a ___ corporation, ___ partnership, ___ proprietorship, ___association,
other (specify) ______________________________________________________________________________
6. INDICATE AFFILIATES OR SUBSIDIARIES TO BE COVERED, IF ANY:
(Include divisions only if all are not to be included)
No. of Employees by Coverage
Name and Location
Nature of
Nature of
Relationship
Business
Life
AD&D
WI
LTD VAR
Other
________________________________________________________________________ _____
__________________
7. POLICY TO BE ISSUED IN THE STATE NEW YORK
8. Requested Effective Date: _________________________
(If other than state of Applicant’s main office, explain in REMARKS)
(Month)
(Day)
(Year)
9. COVERAGES APPLIED FOR: ____Life ____AD&D ____WI ____LTD ____VAR ____OTHER
10. Is any group or blanket insurance now in force or currently being applied for on the Proposed Insureds?___yes ___no
If yes, (A) Indicate in Remarks: name of carrier; type of coverage; effective date; brief benefit description; eligibility;
etc.
(B) Provide prior experience, including premiums and incurred claims (or paid claims and claim reserves at
start and end of period.)
11. Is it proposed to terminate or change any existing group insurance coverage? ___yes ___no
If yes, indicate in Remarks: name of carrier; type of coverage, and date of termination, or date and type of change.
12. Are all Proposed Insureds actively at work? ___yes ___no If not, please list the following for employees not
actively at work:
NAME
DATE OF BIRTH
LAST DAY WORKED
FACE AMOUNT
REASON FOR ABSENCE
REMARKS:
This Preliminary Application is subject to the acceptance and approval in writing by First Reliance Standard Life
Insurance Company at the Office in New York, New York; and nothing contained herein shall be binding upon said
Company until this Preliminary Application is so approved. $______ has been paid herewith. It will be applied toward
the first premium due on the policy or policies if any be issued. Such issuance is subject to the: terms; conditions;
limitations; and exceptions, of the policy or policies if any be issued.
FRAUD WARNING: (Not applicable to life insurance)
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or 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 is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Name of Agent or Broker of Record (print or type)
Share
by______________________________________
_______________________________________ _________%
)
(authorized signature
_______________________________________ _________%
_______________________________________ _________%
______________________________________
)
(title or position with Applicant
Print or type name of Broker’s firm, if applicable
Dated at _________________________________
__________________________________________________
Date_____________________________________
Group
by________________________________________________
Agency____________ Office_________________
(authorized signature)
(title)
FRSL-8209-0594
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Parent category: Business