Application For Insurance Form 2013
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1APPLICATION FOR LIFE INSURANCE
Home Office Use Only
American Mutual Life Association
App. Status: __________ Lodge # _______________
(A Fraternal Benefit Society)
Plan Code: ___________
Contract # _____________
19424 S. Waterloo Road, Cleveland, OH 44119
216-531-1900
Premium: $__________
Issue Date: _____________
Mode: ______________
Issue Age: _____________
Male
Female
Smoker
Non-Smoker
1. Full Name (
): _______________________________________
print
Prem per
Total
2. _____________________________________________________
Plan
Code
Ins. Amt.
$1000
Premium
(Address)
(City)
(State)
(Zip)
W.L.
3. Birth date: MM/DD/YY
_____ Phone #:______________
______
20 PL
Birthplace:__________________ Email:____________________
3 PL
4. Sex: M
F
.
Height: ____ft ____in.
Weight: ________
SPWL
5. Social Security #: _____________ Occupation:_______________
Term
6. Is Proposed Insured a member of the American Mutual Life
Rider(s)
Association? Yes
No
. If no, apply for membership.
Totals
7. If Proposed Insured is not the Applicant, describe relationship of
Paid With Application:
Applicant to Proposed Insured: ______________________________
Div Opt
Pur Pd-up Add
Pay in Cash
Acc at Int.
Red Prem
Relationship:
8. Name and address of Beneficiary:
Social Security #:
Share %:
Primary:
Contingent:
9a. Does the Proposed Insured currently have life insurance on his/her life?
Yes
No.
9b. If yes, is discontinuing premium payments, surrendering, forfeiting, assigning to the insurer or otherwise terminating the existing
policy or contract being considered?
Yes
No. Is using funds from the existing policy or contract to pay premiums due on the
insurance applied for herein being considered?
Yes
No.
10. Within the past 5 years, has Proposed Insured used tobacco in any form? Yes
No
.
11a. Within the past 5 years, has Proposed Insured been hospitalized; or received medical treatment or been diagnosed with any
illness, disease, injury or physical condition? Yes
No
.
11b. Does Proposed Insured have any physical or mental handicaps? Yes
No
.
11c. Give details of YES answers to 10, 11a, and 11b (Tobacco use; Illness or handicap; dates, duration; physicians; and/or hospital):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I AGREE THAT NO INSURANCE SHALL TAKE EFFECT UNLESS AND UNTIL: (1) the first premium shall have been paid; (2) a contract is
delivered to the Applicant during the Proposed Insured’s lifetime; (3) the health of the Proposed Insured is as described in the
Application; and (4) all requirements of the Constitution and Bylaws of the American Mutual Life Association have been complied
with.
Signed at: __________________________________ this: ________ day of: ________________ 20____.
______________________________________________
_________________________________________________
Signature of Agent/Home Office Representative
Applicant
_________________________________________________
Proposed Insured’s Signature Required if not Applicant
(Parent or Guardian if Proposed Insured is under age 16)
Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
application containing a false or deceptive statement is guilty of insurance fraud.
AUTHORIZATION
I hereby authorize any licensed physician; medical practitioner; hospital; clinic other medical or medically related facility; insurance
company; MIB, Inc (“MIB”); or other organization; institution or person that has any record or knowledge of me or my health; to give
to American Mutual Life Association or its representatives; or bearer; or its reinsurers; any such information. Authorization is valid
for no longer than thirty months. A photocopy of this authorization shall be as valid as the original.
Date ______________________________ 20_______.
__________________________________________________
Proposed Insured’s Signature (Parent or Guardian if Proposed
Insured is under age 16)
For Home Office Use
Approved
Remarks: _______________________________________________________________________________________________
Disapproved
_______________________________________________________________________________________________
Dated:_________________________
Signed
_______________________________________________
SF-08
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