Form Ng-Enrl-La - Enrollment For Group Life Insurance, Dd Form 2558 - Authorization To Start, Stop Or Change An Allotment Page 2
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3AMERICAN EQUITY INVESTMENT LIFE INSURANCE COMPANY
ENROLLMENT FOR GROUP LIFE INSURANCE
NATIONAL GUARD ASSOCIATIONS OF LOUISIANA
Policy Number ____________________________Effective Date _____________________ Unit Code No. ___________
I am now an active member of The National Guard. I hereby make application for life insurance for which I am eligible under the
Group Insurance Contract issued to National Guard Associations of Louisiana, by the American Equity Investment Life Insurance
Company of Des Moines, Iowa. The following statements and answers are true and correct to the best of my knowledge and belief.
NAME __________________________________________ GRADE _____________ SSN ___________________________
Last, First, Middle Initial
MAILING ADDRESS__________________________________________________________________________________
Address, City, State, Zip
BENEFICIARY ______________________________________________RELATIONSHIP ______________________
NATIONAL
HOME
GUARD UNIT ________________________________________________TELEPHONE_________________________
MEMBER’S DATE
PLACE OF
DATE OF
OF BIRTH_______________________________ BIRTH ____________________ ENLISTMENT_________________
State
Mo/Day/Year
Mo/Day/Year
1.
Height ________ft.________in.
Weight__________Lbs.
Married
Single
2.
Do you or your dependents know of any impairments now existing in your health or physical condition?
Yes
No
3.
Have you or your dependents had any illness or injuries during the past 3 years?
Yes
No
4.
Have you or your dependents ever had any of the following: Tuberculosis, Rheumatism, Disease of Heart,
Lungs, Stomach, Kidney, Liver, Brain or any other disease or illness?
Yes
No
5.
Have you or your dependents been absent from your regular duties due to illness or injury during the past
six months?
Yes
No
6.
Have you ever been refused, postponed or rated-up by a life insurance company?
Yes
No
If so, give name of company, date and cause ___________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, INDICATE BELOW THE NATURE OF THE ILLNESS OR
INJURY, DURATION, SEVERITY, WITH DATES AND DETAILS AND THE NAME OF PHYSICIAN.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
THIS APPLICATION IS REQUESTED FOR:
NEW ENROLLMENT
INCREASE
GUARD MEMBER
DEPENDENT
SPOUSE
1.
$5,000
($2.00)
2.
$10,000 ($3.66)
6.
$30,000 ($10.34)
3.
$5,000
($3.33)
2.
$10,000 ($3.66)
3.
$15,000 ($5.33)
8.
$40,000 ($13.67)
4.
$10,000 ($6.66)
3.
$15,000 ($5.33)
4.
$20,000 ($7.00)
A.
$50,000 ($17.00)
4.
$20,000 ($7.00)
5.
$25,000 ($8.67)
5.
$25,000 ($8.67)
COMPLETE FOR DEPENDENT OR SPOUSE COVERAGE
Spouse: ________________________________________________________ Spouse DOB: _________________________
Last
First
Middle
Mo/Day/Year
Number of Children Under Age 21:__________ DOB of Oldest Child Under Age 21: ________________________________
Mo/Day/Year
ACKNOWLEGEMENT AND AUTHORIZATION: I hereby authorize any physician, hospital, clinic, insurance company, the MIB,
Inc., or other organization, institution or person that has any records or knowledge of me or of any member of my family or my (our)
health to give this requested information to the American Equity Investment Life Insurance Company (or its reinsurers).
A
photographic copy of this authorization shall be as valid as the original. I hereby assign any experience premium refunds to The
National Guard Associations of Louisiana to be used for purposes which benefit the policies and programs of the National Guard
Associations of Louisiana. I acknowledge receipt of form 5609, “Your Insurance Application and How it is Handled”. Any person
who knowingly presents false or fradulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Dated in _____________________________________________this________day of______________________20_________
13
City, State
_________________________________________________
_____________________________________________
Signature of Member
Signature of Witness
LA-08/2012
NG-ENRL-LA
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